COLLEGE    OF    OSTEOPATHIC    PHYSICIANS 
AND  SURGEONS  •    LOS  ANGELES,  CALIFORNIA 


3 


A    MANUAL    OF    SURGICAL    TREATMENT 


A  .MANUAL 


OF 


SURGICAL  TREATMENT 


«N 

-r        I     By 

W.  WATSON  CHEYNE,  M.B.,  F.R.C.S.,  F.R.S. 

PROFESSOR  OF  SURGERY  IN   KING'S    COLLEGE,    LONDON  ;    SURGEON  TO    KING'S    COLLEGE   HOSPITAL, 
AND   THE   CHILDREN'S    HOSPITAL,    PADDINGTON   GREEN,  ETC. 

and 

F.  F.  BURGHARD,  M.D.  AND  M.S.  (LOND.),  F.R.C.S. 

TEACHER  OF   PRACTICAL   SURGERY   IN  KING'S   COLLEGE,  LONDON  ;   SURGEON   TO    KING'S   COLLEGE 
HOSPITAL,  AND  THE   CHILDREN'S   HOSPITAL,  PADDINGTON   GREEN,  ETC. 


In  Six  Volumes 


VOLUME  I. 

THE  TREATMENT  OF  GENERAL  SURGICAL  DISEASES,  INCLUDING  INFLAMMATION, 
SUPPURATION,  ULCERATION,  GANGRENE,  WOUNDS  AND  THEIR  COM- 
PLICATIONS,  INFECTIVE    DISEASES    AND   TUMORS, 
THE  ADMINISTRATION  OF  ANAESTHETICS, 
BY  DR.  SILK 


LEA  BROTHERS  &  CO. 

PHILADELPHIA   AND    NEW   YORK 
1899 


too 


C 


THE  RIGHT   HON. 

LORD   LISTER,   LL.D.,   P.R.S., 

THE    FOUNDER    OF    MODERN    SURGERY, 

WITHOUT  WHOSE  WORK   MUCH   OF 

THIS   BOOK   COULD   NOT   HAVE 

BEEN   WRITTEN. 


A 
v, 


AUTHORS'    PREFACE. 

THE  subject  of  Surgery  has  now  become  so  extensive  that  any  work 
attempting  to  deal  with  it  in  an  exhaustive  manner  must  necessarily  be- 
so  large  and  unwieldy  as  to  be  suitable  only  for  purposes  of  reference, 
or  for  the  use  of  those  who  devote  themselves  exclusively  to  its  practice. 
In  any  text-book  of  convenient  size  the  information  given  in  certain 
branches  of  the  subject  must  therefore  be  considerably  condensed,  and, 
as  the  first  essential  for  the  beginner  is  to  have  the  fullest  knowledge  of 
the  nature  and  characters  of  the  diseases  that  he  has  to  study,  special 
stress  is  usually  laid  upon  pathology,  symptomatology,  and  diagnosis.  For 
the  practitioner,  on  the  other  hand,  who  is  already  acquainted  with  these 
points,  the  great  essential  is  full  and  detailed  information  as  to  the  best 
methods  of  treatment. 

We  have  ourselves  frequently  experienced  the  want  of  detailed  informa- 
tion, especially  as  regards  the  after-treatment '  of  our  cases,  and  have  had 
to  learn  the  best  methods  of  procedure  from  experience.  Nothing  can 
of  course  replace  experience,  but  it  is  often  of  the  greatest  advantage  to 
have  a  detailed  record  of  that  of  others  upon  which  to  base  one's  work. 
It  is  this  want  that  the  present  work  is  intended  to  supply.  We  have 
tried  to  put  ourselves  in  the  place  of  those  who  have  to  treat  a  given 
case  for  the  first  time,  and  we  have  endeavoured  to  supply  them  with 
details  as  to  treatment  from  the  commencement  to  the  termination  of  the 
illness.  We  have  assumed  that  the  reader  is  familiar  with  the  nature  and 
diagnosis  of  the  disease,  and  we  only  refer  to  the  pathology  and  symptoms 
in  so  far  as  it  is  necessary  to  render  intelligible  the  principles  on  which 
the  treatment  is  based,  and  the  various  stages  of  the  disease  to  which 
each  particular  method  is  applicable. 

We  have  purposely  avoided  attempting  to  give  anything  like  a  complete 
summary  of  the  various  methods  of  treatment  that  have  from  time  to 


viii  PREFACE. 

time  been  proposed :  to  do  so  would  merely  confuse  the  reader. 
Only  those  plans  are  described  which  our  experience  has  led  us  to  believe 
are  the  best,  but  with  regard  to  these  we  have  endeavoured  to  state 
exactly  and  in  detail  what  we  ourselves  should  do  under  given  circumstances. 
In  some  cases  no  doubt  several  methods  of  treatment  are  of  equal  value, 
and  while  we  have  only  discussed  at  length  that  which  we  have  ourselves 
been  led  to  adopt,  we  have  referred  shortly  to  the  others. 

We  have  not  mentioned  all  the  exceptional  conditions  that  may  be 
met  with,  but  we  have  endeavoured  to  include  all  the  circumstances  with 
which  the  surgeon  is  most  commonly  called  upon  to  deal.  The  task  has 
been  one  of  some  difficulty,  the  more  so  as  we  have  had,  to  a  certain 
extent,  to  break  new  ground.  This  must  serve  as  our  excuse  for  the  many 
shortcomings  in  the  work. 

Our  best  thanks  are  due  to  Dr.  Silk  for  much  assistance  in  seeing  this 
volume  through  the  press,  as  well  as  for  his  contribution  upon  the  adminis- 
tration of  anaesthetics.  We  are  also  indebted  to  Messrs.  Down  Brothers 
for  kindly  placing  at  our  disposal  their  very  large  collection  of  blocks 
illustrative  of  surgical  instruments,  to  Messrs.  H.  K.  Lewis  for  Fig.  63, 
to  Messrs.  Arnold  for  Fig.  64,  to  Messrs.  Barth  cS:  Co.  for  Figs.  18  to 
22,  and  to  the  Medical  Neivs  of  New  York  for  Figs.  40  and  41. 

LONDON,  April,  1899. 


TABLE    OF    CONTENTS. 

PART   I. 

CHAPTER  I. — INFLAMMATION. 

I' AGE 

ACUTE  INFLAMMATION  —  Definition. — Pathology:  Results  at  an  early  period — 
Results  at  a  later  period. — Symptoms:  Local  Changes — General  Symptoms. — 
Treatment:  Removal  of  Cause  —  Local  Treatment:  Position  —  Blood-letting 
(General  and  Local) — Cupping — Dry  Cupping — Wet  Cupping — Scarifications — 
Free  Incisions. — Cold:  Evaporating  Lotions — Ice-bag — Leiter's  Tubes.— Heat: 
Poultices  —  Fomentations  —  Spongiopilin.  —  General  Treatment :  Purgative — 
Drinks — Drugs  — Food.  — Prognosis ,  1-15 

CHRONIC  INFLAMMATION — Nature — Causes — Changes  in  the  Tissues — Symptoms.  — 
Treatment :  Local  Treatment :  Rest — Counter-irritation — Pressure — Massage — 
General  Treatment,  -  15-23 

CHAPTER   II. — ACUTE  SUPPURATION. 

ACUTE  SUPPURATION— Definition,       -  24 

SUPPURATION  IN  THE  TISSUES — Causes. — Circumscribed  Acute  Abscess  :  Symptoms — 
Mode  of  Extension — Local  Treatment:  Opening — Drainage — Dressings — After- 
Treatment — General  Treatment. — Diffuse  Cellulitis  :  Symptoms — Local  Treat- 
ment— After-Treatment — General  Treatment,  -  -  24-35 

CHAPTER  III. — ULCERATION. 

ULCERATION — Definition — Classification — Causes,        -  -   36-39 

VARIETIES  OF  ULCER — Simple — Inflamed — Irritable — Weak — Diphtheritic  or  Phage- 

denic — Varicose— Callous — Hsemorrhagic — Pressure — Paralytic — Diabetic,  -    39-41 

DANGERS  OF  ULCERS,  -  -        42 

TREATMENT  OF  ULCERS  IN  GENERAL — Removal  of  Cause — Rest — Promotion  of 
Venous  Return — Absorption  of  Exudation — Avoidance  of  Irritation — Disinfection. 
— Skin  Grafting:  Reverdin's  Method — Thiersch's  Method.  —  Treatment  where 
Patients  cannot  lie «/,  -  -  42-57 

TREATMENT  OF  VARIOUS  FORMS  OF  ULCER — Simple — Inflamed— Weak — Irritable — 
Phagedenic — Varicose — Callous — Pressuie — Paralytic — Perforating  Ulcer  of  Foot 
—  Diabetic,  ....  -  57-62 


CONTENTS. 


CHAPTER  IV. — GANGRKM  . 

PAGE 

GANGRENE — Definition — Classification — Symptoms,     -  -        63 

CLINICAL    CLASSIFICATION — Dry    Gangrene  —  Moist    Gangrene — Treatment,    Local 

and  General,  -   63-64 

ETIOLOGICAL  CLASSIFICATION — Direct  Gangrene:  Gangrene  due  to  Crushing: 
Treatment — Pressure  Gangrene  :  Treatment  of  Bed-Sore — Gangrene  from  Acute 
Inflammation:  Treatment. — Indirect  Gangrene:  Senile  Gangrene  :  Treatment — 
Obstructive  Gangrene :  Treatment — Gangrene  from  Imperfect  Innervation : 
Treatment — "Raynaud's  Disease":  Treatment — Diabetic  Gangrene :  Treatment — 
Seegen's  Dietary—  Gangrene  after  Acute  Fevers:  Treatment — Gangrene  from 
Ergot:  Treatment. — Infective  Gangrene:  Acute  Traumatic  Gangrene:  Treat- 
ment— Phagedena  :  Treatment — Cancrum  Oris  :  Treatment,  -  65-81 


CHAPTER  V. — ANAESTHETICS,  BY  DR.  J.  FREDK.  SILK. 

GENERAL  ANESTHESIA  : 

PREPARATION  OF  THE  PATIENT — Purge — Diet — Nutrient  Enema — Alcohol — Hypo- 
dermic Medication — Morphine — Atropine — Strychnine — Auscultation — Position,  82-85 

CHOICE  OF  THE  ANAESTHETIC — Factors  determining,  -  -   85-87 

NITROUS    OXIDE — Properties —Suitable    Cases — Apparatus    and    Administration — 

Phenomena — Complications — After- Effects —Prolonged  Method,  -  -    87-91 

ETHER — Properties — Suitable  Cases — Apparatus  and  Administration — Clover's  In- 
haler— Ormsby's  Inhaler — Stages  in  Administration — Special  Points — Dangers — 
After-Effects — Nitrous  Oxide  and  Ether  combined,  -  91-98 

CHLOROFORM — Properties — Cases  Suitable — Preparation — Apparatus  and  Adminis- 
tration— Skinner's  Inhaler — Junker's  Inhaler — Phenomena — After- Effects,  -98-103 

MIXTURES — A.C.E.  Mixture:  Properties — Apparatus  and  Administration — Objec- 
tions— Ether  preceded  by  A.C.E. ,  -  103- 107 

ANESTHETICS  IN  SPECIAL  CASES— Intra-cranial  Operations— Operations  about  Nose 

and  Mouth — Enlarged  Thyroids — Severe  Operations — Alcoholics,  107-109 

DIFFICULTIES  AND  DANGERS — Syncope — Respiratory  Paralysis — Signs  of  Danger — 

Treatment,  Prophylactic  and  Active,  110-116 

AFTER-TREATMENT — Sickness — "  Surgical  Shock  " — Diet,     -  116-118 

LOCAL  AN.-ESTHESIA  : 

Advantages — Objections — Cases  Suitable. — Freezing:  Ice  and  Salt — Ether  Spray 
— Ethyl  Chloride — Anaestile. — Drugs:  Cocaine:  Instillation — Sprayed — Painted 
— Hypodermically — Dangers— Eucaine. — Infiltration:  Schleich's  Method,  118-124 


CHAPTER  VI. — WOUNDS.  MANAGEMENT  OF  OPERATIONS  AND  THE  TREAT- 
MENT OF  THEIR  CHIEF  IMMEDIATE  RISKS  :  HAEMORRHAGE,  SHOCK, 
AND  SYNCOPE. 

GENERAL  MANAGEMENT  OF  OPERATIONS — Preparation  of  the  Patient :  Mental 

Attitude — Food — Time  of  Operation — Room,  •  125-127 

DANGERS  OF  OPERATION — Hemorrhage  :  Tourniquet— Esmarch's  Bandage — Lister's 
Method — Ligature — Cautery — Torsion — Pressure — Horsley's  Wax — Cold — Heat 
— Styptics — Fibrin-Ferment — Drugs — Symptoms  of  Serious  Loss  of  Blood — 
Transfusion. — Shock:  Symptoms — Treatment,  prophylactic  and  when  established. 
—  Entry  of  Air  into  Veins:  Treatment. — Syncope:  Treatment,  •-  127-144 

AFTER-TREATMENT  OF  OPERATIONS — Feeding — Aperients,    -  144-146 


CONTENTS.  xi 

CHAPTER  VII. — WOUNDS.     MODES  OF  HEALING. 

PAGE 

MODES  OF  HEALING — Healing  by  "First  Intention"— Healing  by  Blood  Clot — 
Healing  under  a  Scab — Healing  by  Granulation — Healing  by  Union  of  Granu- 
lations— Conditions  inimical  to  Healing  by  First  Intention,  147-151 

CHAPTER  VIII. — WOUNDS.     TREATMENT  OF  INCISED  WOUNDS. 

INCISED  WOUNDS — Classification,         -  152 

TREATMENT  OF  WOUNDS  MADE  BY  THE  SURGEON  THROUGH  UNBROKEN  SKIN — 
Apposition  of  Edges — Approximation  of  Deeper  Structures — Sutures  :  Where  there 
is  no  tension — Where  there  is  great  tension — Where  there  is  moderate  tension — 
Removal  of  Sutures. — Avoidance  of  Movement  and  Irritation — Exclusion  of 
Micro-  Organisms  :  Disinfection  of  Skin,  Hands,  and  Instruments — Preparation 
of  Ligatures  and  Sponges — Swabs — Precautions  during  Operation  :  Towels — 
Mackintoshes — Dress — Management  of  Sponges — Avoidance  of  Aerial  Infection — 
Irrigation — Drainage. — Dressings :  Lister's  Cyanide  Gauze — Pressure — When 
and  how  to  change  Dressings. — After  Progress  of  Wound — l^reatment  without 
Antiseptics — Causes  of  failure  to  secure  healing  by  First  Intention — Treatment 
where  Sepsis  occurs —  Treatment  where  the  Edges  are  not  brought  together : 
Thiersch's  Skin  Grafting — Plastic  Operations — Granulating  Flaps — Occurrence 
of  Sepsis  in  Open  Wounds  :  Treatment,  -  152-181 

WOUNDS    THAT    CANNOT    BE    KEPT    ASEPTIC — Wounds   of  Mucous   Membranes — 

Chloride  of  Zinc — Antistreptococcic  Serum,  182-184 

INCISED  WOUNDS  INFLICTED  ACCIDENTALLY— Treatment — Scalp  Wounds,  -  184-185 

WOUNDS  ALREADY  SEPTIC — Treatment  of  Open   Granulating  Wounds — Treatment 

where  Septic  Sinuses  are  present,   -  185-187 

CHAPTER     IX. — WOUNDS.       PUNCTURED,     CONTUSED,     LACERATED,     AND 
POISONED  WOUNDS  ;   BURNS,  SCALDS,  AND  FROST-BITES. 

PUNCTURED  WOUNDS — Characters— Results — Treatment,       -  188 

CONTUSIONS  AND  CONTUSED  WOUNDS — Characters— Causes— Treatment,  189-190 

LACERATED  WOUNDS — Characters — Causes — Treatment,         -  190-192 

POISONED    WOUNDS — Lupus    Anatomicus  :     Treatment — Local    Septic    Infection — 

General  Septic  Infection :  Treatment,        -  192-194 

BURNS   AND   SCALDS — Degrees   of  Burn — Local   and   Constitutional    Phenomena — 

Causes  of  Death.  —  Treatment :  General — Local,    -  194-200 

EFFECTS  OF  INTENSE  COLD — Chilblains — Ulcers — Frost-bite— Treatment,  Prophyl- 
actic and  Curative,  -  200-204 

CHAPTER  X. — WOUNDS.     INFECTIVE  DISEASES  OF  WOUNDS. 

SEPTIC  INTOXICATION — Symptoms— Treatment,  Local  and  General,  -  205-208 

TRAUMATIC  FEVER— Treatment,  208-209 

ACUTE  SCEPTIC.'EMIA — Symptoms — Treatment,  209-211 

CHRONIC  SCEPTIC^MIA  OR  HECTIC  FEVER — Treatment,  Local  and  General,  211-213 

PY.^EMIA — Pathology  —  Treatment,  Local  and  General. — "Chronic  Pytrmia'" : 

Treatment,-  213-216 

ERYSIPELAS — Symptoms — Varieties — Pathology — Treatment,  Local  and  General — 

Kraske's  Method — Treatment  of  Phlegmonous  cases,  -  216-220 

TETANUS — Definitions-Symptoms — Causes — Varieties — Causes  of  Death — Treatment, 

Prophylactic  and  Curative — Treatment  of  the  Wound — Drugs — Diet,        -  220-223 


xii  CONTENTS. 

CHAPTER  XL — AFFECTIONS  OF  CICATRICES. 

PAGE 

CHELOID— Causes — Treatment :  Pressure — Scarification — Excision,     -  224-225 

CONTRACTING  CICATRIX — Treatment,  -      226 

PAINFUL  CICATRIX — Treatment,  -      226 

ADHERENT  CICATRIX — Treatment,  226-227 

EPITHELIOMA — Treatment,       -  -      227 


CHAPTER  XII. — SYPHILIS. 

SYPHILIS — Definition,   -  -      228 

ACQUIRED  SYPHILIS — Primary  Stage — Secondary  Stage — Tertiary  Stage — Prophy- 
laxis.— Primary  Syphilis  :  Treatment,  General  and  Local — Phagedenic  Chancre. 
— Secondary  Syphilis :  Treatment,  General  and  Local — Administration  of  Mercury. 
— Tertiary  Syphilis :  Treatment,  General  and  Local,  -  228-236 

HEREDITARY  SYPHILIS— Treatment,    -  236-237 


CHAPTER  XIII. — CHANCROID  OR  SOFT  SORE. 

CHANCROID — Definition — Symptoms. — Local  Treatment :  Where  there  is  no  Phimosis 

—  Where  Phimosis  is  present — Phagedenic  Sores. — Central  Treatment,    -  238-240 

TREATMENT  OF  INFLAMED  GLANDS,  -  -  240-241 


CHAPTER  XIV. — TUBERCULOSIS. 

TUBERCULOSIS — Definition — Seats — Accessory  Factors,  Local  and  General — Path- 
ology— Retrogressive  Changes.  —  General  Treatment:  Hygienic  Conditions — 
Drugs,  -  242-247 

CHRONIC  ABSCESS — Pathology.  —  Treatment:  Excision — Partial  Removal  of  Wall — 

Incision  and  Scraping,  -  247-250 


CHAPTER  XV. — TUMOURS. 

TUMOURS — Definition — Clinical  Classification — Histological  Classification,      -  251-252 

TUMOURS  OF  THE  CELLULAR  TYPE- 
EPITHELIAL  TUMOURS — Benign    Varieties:    Papillomata :    Warts:    Treatment- 
Horns  :    Treatment — Corns  :   Treatment — Adenomata  :    Treatment. — Malignant 
Varieties:  Carcinomata — Mode  of  Spread — Treatment  of  Various  Foims,  252-256 

TUMOURS  OF  THE  CONNECTIVE  TISSUE  TYPE — Benign  Varieties:  Myxoma: 
Treatment — Fibromata,  Hard  and  Soft :  Treatment — Lipomata,  Diffuse  and 
Circumscribed  :  Treatment — Chondromata :  Treatment — Osteomata,  Ivory  and 
Spongy:  Treatment. — Malignant  Forms:  Sarcomata:  Round-Celled,  Spindle- 
Celled,  Myeloid,  Melanotic,  Alveolar,  Osteo-Sarcoma,  Chondro-Sarcoma — 
Treatment — Prognosis,  256-262 

TUMOURS  COMPOSED  OP  THE  MORE  COMPLEX  TISSUES — Lymphomata  :  Treatment — 
Myomata  :  Treatment — Neuromata  and  Gliomata  :  Treatment — Angiomata, 
Capillary  and  Cavernous  :  Treatment — Excision — Electrolysis — Caustics — Injec- 
tions— Ligature — Lymphangiomata,  Simple,  Cystic,  and  Cavernous  :  Treatment 
— Cysts — Complex  Tumours  :  Treatment,  262-272 

INDEX,  -  273-285 


LIST    OF    ILLUSTRATIONS. 
PART    I. 


1.  Scarificator  for  use  in  Wet  Cupping,       -  7 

2.  Method  of  applying  an  Ice-bag,  -             -  9 

3.  Letter's  Tubes  applied  spirally  to  a  limb,  10 
3A.               ,,              fixed  to  a  flexible  metal  plate,    -  10 

4.  Lister's  Cautery,    -  19 

5.  Corrigen's  Cautery  and  Portable  Spirit  Lamp,    -  20 

6.  Constant  Irrigation  by  means  of  a  Strand  of  Worsted,  -  30 

7.  Constant  Irrigation  by  means  of  a  Syphon  Tube,  -         31 

8.  Irrigator  (after  Thiersch),  32 

9.  Water  Bath  for  Leg,         -  33 

10.  Water  Bath  for  Hand  and  Forearm,       -  33 

11.  Strapping  an  Ulcer,  44 
2.  Celluloid  Wound  Shields,  48 

13.  Thiersch's  Method  of  Skin-grafting :    Ulcer  prepared  for  Grafting,  -  50 

14.  ,,                     ,,                     ,,             Cutting  the  Grafts,  -         51 

15.  ,,                     ,,                     ,,             Special  Razor  for  Cutting  Grafts,  52 

1 6.  ,,  ,,  ,,  Spreading  the  Grafts  out  upon  the  Raw 

Surface,  53 

17.  ,,                     ,,                     ,,             Application  of  Protective,  -         54 

18.  Nitrous  Oxide  Apparatus,  -         88 

19.  Hewitt's  Apparatus  for  Administration  of  Nitrous  Oxide  ond  Oxygen,  -         90 

20.  Clover's  Portable  Ether  Apparatus,         -  92 

21.  Ormsby's  Ether  Inhaler,  Sectional  View  of,        -  95 

22.  Clover's  Portable  Ether  Apparatus,  fitted  for  Nitrous  Oxide  and  Ether  combined,       97 

23.  Clover's  large  Nitrous  Oxide  and  Ether  Apparatus,       -  98 

24.  Towel  Folded  for  Administration  of  Chloroform.  100 

25.  Graduated  Drop  Bottle  with  Hollow  Stopper,    -  100 

26.  Skinner's  Frame,  -  100 

27.  Junker's  Apparatus  for  Administration  of  Chloroform,   -  101 

28.  Celluloid  Mask  for  A.C.E.  105 

29.  Metal  Mask  for  A.C.E.  or  Ether,  106 

30.  ,,              Sectional  View  of,  -  -       106 

31.  Hahn's  Tracheal  Tampon  and  Chloroform  Attachment,  -       109 

32.  33.  Protection  of  the  Hair  in  Operations  about  the  Head  and  Neck,  -  -       109 

34.  Laryngeal  Forceps,  -       112 

35.  Ferguson's  Mouth  Gag,    -  -       114 


xiv  LIST   OF    ILLUSTRATIONS. 


36.  Tongue  Forceps,  -  114 

37.  Ether  Spray,          -  120 

38.  Metal  Bottle  containing  Ana?stile,  120 

39.  Cocaine  Spray,      -  -122 

40.  41.  Anaesthesia  by  Infiltration  (Schleich),  -  124 

42.  Pressure  Forceps  for  Arrest  of  Haemorrhage,  133 

43.  Transfusion,  -       137 

44.  Hot-Water  Operating  Table,        -  140 

45.  A  Buried  Suture,  154 

46.  Listers  Needle,     -  155 

47.  Method  of  Threading  Lister's  Needle  with  Wire,  156 

48.  Method  of  Suturing  a  Wound  where  there  is  much  Tension  on  the  Edges,  -       156 

49.  Button-hole  or  Blanket  Stitch,    -  158 

50.  Button-hole  Suture:   Methods  of  Finishing  Off,  -       158 

51.  Deep  Suture  for  Approximation  of  Muscular  Planes :    Method  of  Introducing 

the  Sutures,  -  167 

52.  „                                ,,                               ,,                The  Sutures  tied,  -       168 
53>  54-  Method  of  employing  Elastic  Pressure  to  keep  Dressings  in  Position,  -  171 

55.  Barker's  Flushing  Spoon,  -       176 

56.  Plastic  Operations  :    How  to  fill  up  a  quadrilateral  defect  of  moderate  size,  -       178 

57.  ,,                 ,,             How  to  fill  up  a  quadrilateral  defect  of  large  size,  -       178 

58.  ,,                 ,,             How  to  fill  up  a  triangular  defect  of  moderate  size,  -       179 

59.  ,,                 ,,             How  to  fill  up  a  triangular  gap  of  large  size,       -  179 

60.  „  ,,  To  fill  in  a  triangular  gap  by  means  of  curved  incisions,        179 

61.  Keith's  Glass  Drainage  Tube,      -  -       207 

62.  Kraske's  Method  of  Treatment  for  Erysipelas,  -  -       219 

63.  Methods  of  Inserting  the  Needles  in  Electrolysis  of  a  Nsevus  (Louis  Joins),  -      267 

64.  Bipolar  Fork  Electrode  (Lewis  Jones),    -                                                  •  -      267 

65.  Temporary  Strangulation  of  a  Naevus  :    Method  of  passing  the  Ligatures,  -       270 

66.  ,,                                         ,,               Method  of  dividing  the  Ligatures,  -       270 


CHAPTER    I. 

INFLAMMATION. 

DEFINITION. — Inflammation  may  be  defined  as  the  first  series  of 
changes  that  occurs  in  a  tissue  as  the  result  of  an  injury,  provided  always  that 
this  has  not  been  of  sufficient  violence  to  at  once  destroy  the  vitality  of  the 
part.  Whenever  an  injury  is  done  to  a  part,  whether  it  be  of  a  chemical 
or  a  mechanical  nature,  a  certain  series  of  changes  at  once  commences  there, 
and  this  series  of  changes,  so  long  as  it  is  of  an  exudative  or  destructive 
character,  we  call  inflammation.  The  amount  of  inflammatory  change  in 
the  tissue  will  depend  upon  the  length  of  time  that  the  process  goes  on, 
and  the  severity  and  result  of  the  inflammation  will  be  in  proportion  to 
the  length  of  time  that  the  irritant  exerts  its  influence,  and  the  intensity 
with  which  it  acts.  Inflammation  is  divided  into  acute  and  chronic  inflam- 
mation. 

ACUTE    INFLAMMATION. 

PATHOLOGY. — It  is  only  necessary  here  to  enumerate  the  changes 
that  take  place  in  the  tissues  during  inflammation.  They  consist  in  the  first 
instance  of  dilatation  of  the  blood-vessels,  preceded  in  some  cases  by  con- 
traction. This  dilatation  affects  more  especially  the  small  arteries  and 
capillaries,  but  also  to  some  extent  the  veins. 

Results  at  early  period. — In  the  early  stages  the  circulation  of  the 
blood  is  quickened,  but  slowing  of  the  blood-stream  soon  becomes  evident, 
until,  in  severe  cases,  complete  stasis  or  coagulation  of  the  blood  takes  place 
within  the  vessels  at  the  focus  of  the  inflammation.  During  this  period 
also,  fluid  collects  in  the  surrounding  tissues,  which  become  much  swollen. 
This  fluid  is  probably  in  the  main  derived  from  the  blood  plasma,  but  in 
part  it  is  lymph  retained  in  the  tissues;  and  not  only  does  fluid  accumulate 
outside  the  vessels  and  coagulate  there,  but  the  white  corpuscles  pass 
out  in  large  numbers  through  the  walls  of  the  veins,  and  to  some  extent 
through  those  of  the  capillaries  as  well.  In  certain  inflammations  also,  red 
blood-corpuscles  may  escape  from  the  blood-vessels.  At  this  stage,  if  the 
cause  has  ceased  to  act,  the  inflammatory  process  may  come  to  a  stop, 

A 


2  INFLAMMATION. 

and  the  process  known  as  resolution  may  set  in.  That  is  to  say,  the 
exuded  material  becomes  broken  up  and  removed  by  the  lymphatic  vessels, 
the  migrated  corpuscles  either  re-enter  the  blood-vessels  or  the  lymphatics, 
or  break  down  and  are  carried  away  in  the  form  of  debris.  The  dilated 
vessels  also  gradually  regain  their  tone,  and  ultimately  the  part  resumes  its 
normal  appearance  and  structure.  On  the  other  hand,  in  very  severe 
inflammation,  the  stasis  and  exudation  may  be  so  great  as  to  lead  to 
gangrene  of  the  part  even  at  this  early  stage. 

Results  at  later  period. — In  most  cases  inflammation  that  has  gone 
on  to  this  degree  proceeds  further,  and  the  tissues  gradually  disappear  as 
the  result  of  the  inflammatory  process,  the  original  tissue  being  replaced  by 
what  is  known  as  granulation  tissue.  This  is  composed,  in  the  first  instance, 
of  round  cells  and  embryonic  blood-vessels.  The  inflammation  thus  passes 
on  to  the  stage  of  granulation,  and  when  this  stage  is  reached  one  of  three 
things  may  happen.  In  the  first  place,  the  irritant  may  cease  to  act,  in 
which  case  the  process  subsides  and  retrogressive  changes  take  place.  The 
cells  which  compose  the  granulation  tissue  then  develop  into  fibrous  tissue, 
and  the  blood-vessels  diminish  in  number  and  become  blocked  by  a  process 
analogous  to  arteritis,  but  the  ultimate  result  is  the  formation  of  scar  tissue, 
and  not  restoration  of  the  part  to  its  normal  condition,  as  is  the  case  in 
resolution.  More  usually,  however,  where  inflammation  has  gone  on  to 
the  stage  of  granulation,  we  have  to  do  with  a  more  persistent  cause  of 
inflammation,  and  therefore  suppuration  results.  Thirdly,  where  the  in- 
flammatory process  affects  the  skin  or  mucous  membrane,  and  is  not  very 
violent,  the  result  known  as  ulceration  follows. 

SYMPTOMS.— We  shall  here  deal  with  the  early  stages  of  inflam- 
mation, before  suppuration  or  the  other  processes  above  enumerated  have 
supervened.  At  this  early  stage  the  symptoms  of  inflammation  are  partly 
local  and  partly  general.  The  local  changes  are  diffuse  redness  of  the 
part,  most  intense  at  the  centre,  and  swelling,  which  sometimes  reaches  a 
marked  degree,  and  varies  in  character  at  different  parts,  being  hard  and 
brawny  towards  the  centre  of  the  inflammatory  area,  and  soft  and  oede- 
matous  towards  its  margins.  There  is  also  heat,  and,  lastly,  severe  pain, 
which  is  usually  of  a  throbbing  character,  being  worse  where  the  inflam- 
mation affects  dense  tissues  and  when  the  part  assumes  the  dependent 
position.  The  general  symptoms  of  inflammation  vary  with  its  situation, 
extent,  and  nature,  and  present  two  great  types.  In  the  first  type  of 
inflammatory  fever,  which  is  termed  the  sthenic  fever,  there  is  headache 
and  anorexia,  the  temperature  is  high,  running  up  rapidly  to  103°  or  104°, 
the  pulse  becomes  rapid,  varying  from  100  to  112,  and  is  full,  not  easily 
compressible,  and  quite  regular.  The  tongue  is  furred,  white  and  moist, 
the  skin  is  hot  and  dry,  the  bowels  are  constipated,  and  the  urine  is  scanty 
and  high-coloured.  If  delirium  be  present,  as  it  very  often  is,  it  is  of  a 
noisy  and  violent  character ;  in  fact,  the  general  type  of  this  form  of 
inflammatory  fever  is  that  of  strong  reaction,  and  the  patient  does  not 


ACUTE    INFLAMMATION.  3 

present  any  marked  features  of  depression.  On  the  other  hand,  another 
type  termed  the  asthenic  inflammatory  fever  is  met  with  in  certain  cases  ; 
of  this  the  great  characteristic  is  marked  depression  of  the  vital  powers. 
The  temperature,  as  in  the  other  case,  is  high,  but  the  pulse  is  quicker 
and  may  run  up  to  130,  and  is  soft  and  thready  and  quite  easily  compres- 
sible. The  tongue  is  dry  and  brown,  delirium,  if  present,  is  of  a  low 
muttering  character,  and  the  patient  is  generally  in  a  semi-conscious  state. 

TREATMENT. — The  treatment  of  inflammation  must  be  considered 
under  the  heads  of  local  and  general  treatment.  The  great  characteristic 
of  the  inflammatory  changes  is  that  they  only  continue  as  long  as  the  cause 
which  produces  them  continues  to  act.  As  soon  as  the  cause  ceases  to 
act,  the  inflammatory  changes  very  quickly  come  to  a  standstill,  and  then 
either  resolution  or  retrogression  takes  place. 

Removal  Of  cause. — Hence,  in  the  treatment  of  inflammation,  the  first 
great  question  is  to  ascertain  whether  or  not  it  is  possible  to  remove  the 
cause.  The  causes  of  inflammation  will  be  discussed  more  in  detail  under 
the  heading  of  suppuration,  but  they  may  be  divided,  as  regards  treatment, 
into  two  classes,  namely,  those  which  are  removable  and  those  which  are 
not  readily  got  rid  of.  Removable  causes  are  foreign  bodies,  chemical 
irritants,  and  the  like.  The  irremovable  causes  are  micro-organisms  growing 
in  the  tissues,  and  they  are,  unfortunately,  the  more  common.  The  action 
of  these  micro-organisms,  however,  is  to  a  certain  extent  dependent  upon, 
or  influenced  by,  various  circumstances  which  favour  their  growth.  There- 
fore, if  any  foreign  body  or  other  removable  cause  is  present,  remove  it, 
and  if  there  is  no  cause  that  can  be  removed,  try  to  put  the  tissues 
under  the  most  favourable  circumstances  to  resist  the  growth  of  the  parasite, 
and,  moreover,  get  rid  of  anything  which  is  aiding  its  development. 

Local  Treatment. — The  most  obvious  symptom  in  inflammation  is  the 
congestion  of  the  part,  and  the  first  point  in  the  local  treatment  of 
acute  inflammatory  trouble,  in  cases  where  the  cause  is  irremovable,  is  to 
attempt  to  diminish  this  congestion  as  far  as  possible.  If  one  succeeds 
in  diminishing  the  congestion  one  will  also  lessen  the  pain  and  the  exuda- 
tion, and  possibly  also  to  some  extent  the  constitutional  disturbance. 

Position. — The  first  way  in  which  congestion  of  a  part  should  be  relieved 
is  by  attention  to  its  proper  position.  When  an  inflamed  part  is  allowed 
to  hang  down,  the  throbbing  and  the  pain  are  very  much  increased,  as 
the  result  of  the  dilatation  of  the  blood-vessels.  The  first  essential  in 
the  treatment  of  acute  inflammation,  therefore,  is  to  raise  the  inflamed 
part  so  as  to  place  it,  if  possible,  on  a  higher  level  than  the  heart,  and  by 
this  means  to  diminish  the  congestion,  not  only  by  the  mechanical  emptying 
of  the  veins,  but  also  by  the  production  of  reflex  contraction  of  the  arteries. 

Blood-letting. — A  second  method,  by  which  the  congestion  of  the  part 
may  be  relieved  and  the  local  symptoms  considerably  subdued,  is  by  blood 
letting,  and  this  may  be  employed  either  in  the  form  of  general  or  local 
blood-letting. 


4  INFLAMMATION. 

(a)  General  blood-letting,  or  the  removal  of  a  considerable  quantity 
of  blood  from  the  general  circulation  without  any  special  reference  to  the 
seat  of  the  inflammation,  probably  acts  by  lowering  the  action  of  the 
heart,  producing  faintness,  and  so  diminishing  the  circulation  in  the 
affected  part.  It  is  also  possible  that  the  loss  of  a  considerable  quantity 
of  blood  may,  to  some  extent,  alter  the  constitution  of  the  remaining  blood 
serum,  and  render  it  more  active  as  an  anti-bacteric  agent.  General 
blood-letting,  which  was  formerly  much  in  vogue,  is  but  seldom  prac- 
tised nowadays.  It  is  best  carried  out  by  opening  a  vein,  the  one 
usually  chosen  being  the  median  basilic  vein,  which  is  preferred  to 
others  on  account  of  its  constant  large  size  and  its  ready  accessibility. 
The  patient  should  sit  upright  upon  a  couch,  so  that  he  can  lie  down 
immediately  if  he  feels  faint ;  the  sitting  position  has  the  further  advan- 
tage that  the  patient  will  become  faint  sooner  than  if  he  were  lying  down, 
and  thus  a  certain  safeguard  is  provided  against  the  withdrawal  of  too 
much  blood.  Venesection  should  never  be  practised  with  the  patient  in 
the  recumbent  position.  A  bandage  is  tied  in  a  bow  round  the  upper 
arm,  tight  enough  to  cause  engorgement  of  the  veins,  but  not  sufficiently 
tight  to  interfere  with  the  arterial  flow.  The  superficial  veins  are  still 
further  distended  by  making  the  patient  grasp  a  stick,  as  by  this  means 
the  blood  is  forced  from  the  deep  veins  into  the  superficial  ones.  The 
surgeon  stands  in  front  of  the  patient,  grasps  the  arm  with  his  left  hand, 
and  steadies  the  median  basilic  vein  by  placing  the  left  thumb  upon  it 
immediately  below  the  intended  seat  of  puncture,  and  then,  with  a  sharp 
double-edged  lancet,  an  oblique  incision  is  made  through  the  skin  and 
the  anterior  wall  of  the  vein,  the  posterior  wall  of  which  should  not  be 
divided.  The  incision  should  divide  both  the  skin  and  the  wall  of  the 
vein  at  one  cut,  and  should  be  oblique  to  the  long  axis  of  the  vein. 
The  blood  flows  in  a  jet  from  the  incision  in  the  vein,  and  is  received 
into  a  graduated  porringer.  It  is  generally  the  custom  to  slip  the  left 
thumb  over  the  incision  in  the  vein  as  soon  as  it  is  made,  so  as  to  prevent 
bleeding  until  the  porringer  is  ready.  The  amount  of  blood  usually  with- 
drawn is  from  about  eight  to  ten  ounces;  in  former  days  the  patient  was 
bled  until  he  felt  faint  or  until  he  actually  fainted.  After  a  sufficient  quantity 
of  blood  has  been  withdrawn,  the  bandage  around  the  upper  arm  is 
removed,  a  small  pad  of  cyanide  gauze  placed  over  the  skin  incision,  and 
kept  in  position  by  a  few  turns  of  a  figure-of-eight  bandage.  This  suffices 
to  arrest  the  bleeding,  and  in  a  few  days  the  wound  will  be  healed  and 
the  circulation  re-established.  The  patient  should  be  directed  to  keep  his 
arm  in  a  sling  for  four  or  five  days.  Although  this  is  but  a  small  operation, 
it  is  well  to  perform  it  with  full  antiseptic  precautions,  the  patient's  skin, 
the  operator's  hands  and  the  lancet  being  thoroughly  purified  in  the  ordinary 
manner;1  in  former  times  patients  occasionally  lost  their  lives  from  septic 
thrombosis.  The  operation  itself  is  perfectly  easy,  but  care  must  be  taken 
1For  the  methods  of  disinfection  of  skin,  instruments,  etc.,  see  Chap.  VIII. 


ACUTE    INFLAMMATION.  5 

not  to  allow  the  knife  to  go  too  deeply,  for  it  has  occasionally  happened 
that  the  brachial  artery  has  been  punctured  by  the  lancet,  with  the  result 
that  aneurismal  varix  has  subsequently  formed.  Another  vein  which  used 
to  be  frequently  opened  is  the  external  jugular  vein  as  it  crosses  over  the 
sterno-mastoid  muscle,  but  the  risk  there  is  greater,  because  air  may  enter 
the  vein  and  cause  serious  circulatory  trouble.  The  operation  in  this 
situation  possesses  no  countervailing  advantages  in  the  case  of  inflamma- 
tion, and  we  shall  not  describe  it. 

(b)  At  the  present  day,  however,  we  have  to  consider  not  so  much 
general  as  local  blood-letting,  the  former  method  being  almost  entirely 
restricted  to  such  inflammatory  conditions  as  those  of  the  lungs,  and  some- 
times of  the  brain,  characterised  by  engorgement  of  the  right  side  of  the 
heart.  The  means  employed  for  local  blood-letting  are  threefold,  namely, 
the  application  of  leeches,  the  use  of  cupping,  and  incisions  or  scarifications. 
As  to  the  manner  in  which  local  blood-letting  acts,  it  is  assumed  that,  by 
withdrawing  a  little  blood  from  the  skin  in  the  neighbourhood  of  the 
inflammation,  less  blood  is  carried  to  the  inflamed  part,  either  because 
afferent  vessels  are  cut,  or,  more  probably,  because  reflex  contraction  of 
the  other  vessels  takes  place  through  the  agency  of  the  nervous  system. 

We  shall  first  consider  the  application  of  leeches,  with  regard  to 
which  several  points  require  to  be  mentioned.  In  the  first  place,  the  part 
to  which  the  leeches  are  to  be  applied  must  be  carefully  cleansed,  as 
otherwise  they  do  not  readily  bite,  and  if  there  is  any  difficulty,  the  appli- 
cation of  a  little  cream  or  milk  to  the  skin  will  sometimes  prove  effectual 
in  making  them  do  so.  When  the  leeches  are  put  on  the  skin,  it  is  very 
necessary  to  confine  them  until  they  have  taken  a  good  hold,  because 
as  a  rule  they  do  not  bite  directly  they  are  applied.  This  is  most  con- 
veniently done  by  inverting  over  them  the  bottom  of  a  pill-box,  from 
which  the  top  has  been  removed.  In  a  short  time  they  will  fix  themselves, 
and  the  pill-box  can  then  be  taken  away.  Special  leech-glasses  are  employed 
for  this  purpose,  and  they  answer  admirably ;  but  in  using  them  it  is  of 
course  necessary  to  see  that  the  leech  is  put  tail  first  (the  thick  end  of  the 
leech)  and  not  head  first  into  the  glass.  This  seems  an  unnecessary  remark, 
but  nevertheless  the  mistake  is  not  uncommonly  made  by  students.  A 
narrow  test  tube  answers  the  purpose  of  a  leech-glass  excellently.  Several 
accidents  have  taken  place  where  leeches  have  been  left  free,  on  account 
of  their  having  wandered  into  mucous  canals,  such  as  the  rectum 
or  the  vagina,  and  there  caused  considerable  mischief.  When  a  leech 
has  been  applied  it  is  allowed  to  suck  its  fill,  and  the  amount  of 
blood  which  an  individual  leech  will  abstract  is  from  a  drachm  to  a 
drachm  and  a  half.  As  a  rule,  when  it  has  sucked  as  much  blood  as 
it  will  hold,  it  falls  off,  but  should  there  be  any  delay  in  its  detachment, 
it  can  be  hastened  by  applying  some  salt  and  water  to  it.  When  a  leech 
has  been  removed,  and  it  is  proposed  to  use  it  again,  it  should  be  placed 
for  a  short  time  in  salt  and  water,  and  this  has  the  effect  of  making  it 


6  INFLAMMATION. 

vomit  the  blood  which  it  has  swallowed.  The  wound  made  by  the  leech 
is  tri-radiate  and  does  not  extend  deeply  into  the  skin,  and,  were  there  no 
provision  for  preventing  it,  coagulation  would  occur,  and  very  little  blood 
be  obtained  from  the  wound  after  the  leech  has  detached  itself.  In  the 
throat  of  the  leech,  however,  there  is  a  gland  secreting  a  substance  which 
prevents  the  coagulation  of  the  blood,  and  it  is  probable  that  the  cases 
in  which  there  is  much  trouble  from  bleeding  after  the  application  of 
leeches  are  explained  by  the  fact  that  this  secretion  has  been  left  in  con- 
siderable quantity  in  the  wound. 

Bleeding  from  leech-bites. — As  a  rule,  bleeding  from  a  leech-bite  stops 
very  soon  after  the  leech  has  been  removed.  In  fact,  in  many  cases  warm 
fomentations  have  to  be  applied  to  the  part  if  it  is  desired  to  promote 
additional  bleeding.  In  some  cases,  however,  the  bleeding  does  not  stop, 
and  considerable  trouble  ensues  from  difficulty  in  arresting  the  oozing 
which  goes  on.  Where  it  does  not  stop  of  itself,  a  pad  and  bandage  pro- 
perly applied  will  usually  suffice,  but,  if  not,  the  skin  around  the  leech-bite 
should  be  pinched  up,  so  as  to  stop  the  bleeding  temporarily,  and  then  the 
bite  is  carefully  dried  and  flexile  collodion  painted  over  it  and  allowed  to 
dry  before  the  pressure  is  relaxed.  If  this  fails,  a  hare-lip  pin  may  be 
passed  under  the  wound  and  a  piece  of  silk  firmly  twisted  over  the  pro- 
jecting ends  in  a  figure-of-eight.  Should  this  be  insufficient,  it  may  be 
necessary  to  use  some  styptic,  such  as  perchloride  of  iron,  the  small  wound 
being  pinched  up  to  arrest  the  bleeding  temporarily  and  the  liquor  ferri 
perchloridi  applied  to  the  cut  surface.  Even  this  may  fail,  and,  if  the 
bleeding  still  goes  on,  it  is  best  to  excise  the  leech-bite  altogether,  leaving 
a  deeper  wound  which  can  be  stitched  together.  The  object  of  excising 
the  leech-bite  is  to  remove  the  tissue  which  is  impregnated  with  the  material 
from  the  leech's  throat.  In  view  of  the  possibility  of  the  haemorrhage 
proving  troublesome,  it  is  not  advisable  to  apply  leeches  to  a  part  which 
cannot  be  corripressed  against  a  bone.  For  instance,  they  should  not  be 
applied  to  the  scrotum ;  if  leeching  is  required  in  that  situation  the  leech 
should  be  placed  on  one  or  other  side  of  the  perineum,  where  pressure  can 
be  applied  against  the  pubic  bone.  Where  it  is  required  to  apply  leeches 
for  affections  of  the  eye,  the  best  plan  is  to  shave  a  little  of  the  hair  from 
the  temple  and  apply  the  leech  in  that  situation.  Firm  pressure  can  then 
very  easily  be  applied,  if  necessary,  and  the  hair  when  it  grows  again  will 
cover  the  mark  of  the  bite  satisfactorily.  Cases  have  occurred  where,  when 
leeches  have  been  applied  late  in  the  evening,  and  the  bleeding  has  not 
been  noticed,  the  patient  has  lost  a  large  quantity  of  blood  by  the  morning. 
It  is  therefore  well  to  apply  them  in  the  forenoon,  so  that  bleeding  may 
be  readily  observed. 

The  second  method  of  blood-letting  employed  in  inflammation  is  Cupping. 
For  the  purpose  of  actually  removing  blood,  wet  cupping  is  the  plan  used, 
but  a  good  deal  of  benefit  is  in  some  cases  derived  from  the  employment 
of  Dry  Cupping,  which  consists  in  the  application  of  the  cups  without  any 


ACUTE    INFLAMMATION. 


previous  scarification  of  the  skin,  and  therefore  without  any  loss  of  blood 
to  the  patient.  Either  the  special  cup  which  is  sold  for  the  purpose  may 
be  used,  or  a  small  tumbler,  which  answers  equally  well,  and  the  edge  of 
this  should  be  oiled.  A  piece  of  blotting  paper  about  two  inches  square 
is  dipped  in  methylated  spirit  and  placed  in  the  bottom  of  the  glass, 
and  this  is  set  on  fire  with  a  match.  As  soon  as  it  has  burned  a  few 
seconds  the  glass  is  inverted  over  the  skin  (which  should  previously  have 
been  sponged  with  warm  water),  and,  as  the  heated  air  in  the  glass  con- 
tracts on  cooling,  a  partial  vacuum  is  created,  the  skin  and  subcutaneous 
tissues  being  drawn  up  into  the  interior  and  forming  a  prominent  mass  full 
of  blood.  A  number  of  cups  may  be  applied  in  this  way  and  left  on  for 
a  considerable  time.  After  a  time,  when  the  swelling  of  the  skin  has 
increased  to  such  an  extent  as  to  replace  the  air  lost  by  the  heat,  they 
become  loose  ;  but,  should  it  be  desired  to  remove  the  cups  previously, 
this  is  quite  easily  done  by  insinuating  the  finger-nail  beneath  the  rim  of 
the  cup,  so  as  to  allow  of  the  entrance  of  a  little  air ;  the  cup  can  then 
be  readily  lifted  off. 

Where  Wet  Cupping  is  employed,  the  skin  is  first  scarified  in  a  num- 
ber of  places,  either  by  means  of  a  special  machine  made  for  the  purpose 
(see  Fig.  i),  or  by  means  of  an  ordinary  lancet. 
The  incisions  should  not  go  deeply  into  the  skin. 
It  is  sufficient  to  go  deep  enough  to  draw  a  little 
blood;  if  the  skin  be  cut  through,  until  the  fat  is 
exposed,  small  pellets  of  the  latter  will  be  drawn 
up  and  plug  the  orifices  and  stop  the  bleeding. 
The  object  is  to  open  as  large  a  number  of 
capillaries  as  possible.  When  this  is  done,  the 
cup  is  applied  in  the  manner  already  described, 
directly  over  the  scarified  area.  The  result  is 
that,  as  a  consequence  of  the  partial  vacuum, 
blood  is  drawn  out  of  the  part  until  the  place 
of  the  air  is  taken  by  the  blood  which  issues 
from  the  skin  ;  the  cup  then  gets  loose  and  can 
be  removed.  If  further  bleeding  be  required  it 
can  be  promoted  by  the  application  of  warm 
fomentations,  or  the  scarified  surface  may  be 
sponged  free  of  clots  and  the  cup  again  applied 
as  before.  Wet  cupping  is  a  most  convenient 
method  of  withdrawing  blood  locally,  but  the 

quantity  removed  by  each  cup  is  comparatively  small,  being  from  one  to 
three  drachms.  This  method  of  treatment  is  especially  useful  in  the  lumbar 
region,  for  renal  affections.  There  is  no  trouble  in  arresting  the  bleeding 
after  wet  cupping  performed  in  the  manner  described. 

The  last  method  of  local  blood-letting  is  that  of  scarifications  and  free 
incisions.      The   Scarifications  are  made  by  a  lancet  with  the  precautions 


FlG.  I. — SCARIFICATOR  FOR  USE 

IN  WET  CUPPING.  The  instru- 
ment, with  the  blades  concealed 
(which  is  done  by  pulling  the  large 
trigger  handle),  is  pressed  flat 
against  the  skin,  and  the  blades 
are  made  to  protrude  by  pressure 
on  the  button  at  the  side  of  the 
figure.  The  depth  to  which  the 
blades  project  is  regulated  by  a 
screw  seen  at  the  bottom  of  the 
figure. 


8  INFLAMMATION. 

already  referred  to  in  describing  cupping,  and  they  are  mostly  used  in 
cases  of  inflammation  affecting  mucous  membranes.  For  example,  in  inflam- 
mation about  the  back  of  the  throat,  when  there  is  oedema  of  the  glottis, 
much  good  may  result  from  early  scarification  of  the  part,  which  is  carried 
out  by  means  of  a  small  curved  lancet  introduced  through  the  mouth. 

Free  Incisions  into  an  inflamed  part  will  often  prove  of  the  very  greatest 
value  in  acute  inflammatory  conditions,  and  they  act  not  only  by  allowing 
the  escape  of  blood  from  the  engorged  blood-vessels,  but  also  by  permitting 
the  escape  of  the  exudation,  which  might  otherwise  cause  very  much  damage 
from  pressure  upon  the  blood-vessels.  This  is  more  especially  the  case 
in  inflammations  in  dense  tissues,  such  as  the  periosteum  and  bone,  where 
the  blood-vessels  are  confined  within  rigid  canals,  and  where  the  pressure 
of  the  exudation  in  these  canals  may  be  so  great  as  to  obliterate  the 
vessels,  and  so  prevent  the  blood-supply  reaching  the  bone.  In  com- 
mencing acute  suppurative  periostitis  and  osteomyelitis,  it  is  imperative,  if 
extensive  necrosis  is  to  be  avoided,  to  make  free  incisions  through  the 
periosteum  as  soon  as  the  case  is  diagnosed,  and,  in  the  case  of  osteo- 
myelitis, to  remove  portions  of  bone  so  as  to  freely  open  the  medullary 
cavity.  If  this  be  done  with  antiseptic  precautions,  a  very  considerable 
number  of  cases  will  be  saved  from  the  impending  necrosis. 

Cold. — Other  methods  of  diminishing  the  local  trouble  in  inflamma- 
tion are  the  use  of  cold  or  heat  At  first  sight  these  methods  may 
seem  contradictory,  but  each  has  its  use  and  neither  can  be  altogether 
dispensed  with.  Cold  is  supposed  to  act  by  contracting  the  blood-vessels 
going  to  the  part,  and  so  diminishing  the  flow  of  blood  through  it. 
A  certain  amount  of  danger  is  associated  with  the  use  of  cold,  as  the 
vitality  of  the  tissues  may  be  so  depressed  by  it  that,  where  the  inflam- 
mation is  severe,  actual  death  of  the  tissue  may  follow  its  prolonged  appli- 
cation, and  this  is  a  point  which  should  be  carefully  borne  in  mind.  Not 
only  does  the  cold  of  itself  depress  the  vitality  of  the  part,  but  it  slows  the 
circulation  so  that  the  blood  becomes  venous,  and  thus  in  another  way  the 
nutrition  of  the  part  is  interfered  with.  Hence  the  use  of  cold  should  be 
limited  to  the  early  stages  of  inflammation,  for  directly  much  exudation  has 
taken  place  it  is  hardly  likely  that  cold  will  arrest  the  further  progress  of 
the  trouble,  while  the  danger  of  weakening  the  tissue  is  especially  great. 

Cold  may  be  applied  in  various  ways.  Probably  the  mildest  form  of 
using  cold  is  by  the  application  of  one  or  other  of  the  ordinary  Evaporating 
Lotions.  A  good  evaporating  lotion  consists  of  half  an  ounce  of  chloride 
of  ammonium,  one  ounce  of  rectified  spirit,  and  seven  ounces  of  water. 
Another  good  formula  is  : 

Ammonii  chloridi,  -  5ss. 

Aceti  destillati,        ...  -  5j. 

Spiritus  rectificati, 5j- 

Aquam  ad, =; 

Misce.  Ft.  lotio. 


ACUTE    INFLAMMATION.  9 

A  piece  of  thin  muslin  dipped  in  the  lotion  is  placed  over  the  skin  and 
kept  constantly  moist,  the  part  being  left  freely  exposed  to  the  air,  so 
that  evaporation  may  go  on  rapidly.  The  patient  himself  is  generally  able 
to  look  after  this.  Another  lotion  which  is  much  used  is  lead  lotion,  or, 
where  there  is  much  pain,  lead  and  opium  lotion.  The  lead  lotion  is  the 
liquor  plumbi  subacetatis  dilutus  of  the  Pharmacopoeia,  and  in  order  to 
make  the  lead  and  opium  lotion,  10  to  20  minims  of  laudanum  is  added  to 
each  ounce  of  the  liquor  plumbi.  This  is  used  in  the  same  way  as  the 
above. 

If  greater  lowering  of  temperature  be  required,  dry  cold  should  be  used, 
because  the  wet  form  is  more  apt  to  lead  to  gangrene  than  the  dry.  Dry 
cold  is  best  applied  by  means  of  an  Ice-Bag,  crushed  ice  being  placed  in 
an  indiarubber  bag,  and  the  latter  so  suspended  over  the  part  that  the  weight 
of  the  ice  does  not  cause  pressure  upon  it.  The  ice,  of  course,  will 
require  renewal  as  it  melts,  and  the  condition  of  the  ice-bag  should  be 
frequently  inspected.  A  very  convenient  way  is  to  tie  the  ice-bag  to  the 


FIG.  2. — METHOD  OF  APPLYING  AN  ICE-BAG. 


upper  part  of  one  of  the  cradles  which  are  used  for  protecting  limbs  in 
the  case  of  fracture,  etc.,  and  so  arranging  the  height  of  the  ice-bag  that 
it  just  touches  the  part  where  cold  is  required.  Between  the  ice-bag  and 
the  skin  a  piece  of  lint  should  be  placed,  in  order  to  absorb  the  moisture 
which  is  apt  to  accumulate  there  (see  Fig.  2).  In  employing  cold  in  acute 
inflammation,  the  condition  of  the  part  should  be  carefully  watched  from 
time  to  time,  and  if  the  skin  become  dusky  from  excess  of  venous 
blood,  or  if  the  circulation  in  it  be  markedly  slowed,  as  will  be  shown  by 
pressing  the  part  and  watching  the  rapidity  with  which  the  vessels  fill 
again,  the  use  of  cold  should  at  once  be  abandoned  and  the  part  wrapped 
up  in  cotton  wool. 

A  still  more  effectual  way  of  employing  cold  is  by  means  of  the  appar- 
atus known  as  Letter's  Tubes.  These  consist  of  fine  lead  tubing  which 
can  be  twisted  into  a  flat  spiral  coil  and  then  so  moulded  as  to  surround 
the  part  without  causing  any  undue  pressure.  Through  these  tubes  a  con- 
stant stream  of  water  is  passed,  and,  according  to  the  temperature  of  the 
water,  any  degree  of  cold  can  be  obtained.  Between  the  Leiter's  tubes 


IO 


INFLAMMATION. 


and  the  skin  a  piece   of  lint  should  be  placed,  for  the  reason  just  men- 
tioned with  regard  to  the  ice-bag  (see  Figs.  3  and  $A) 


FIG.  3. — LEITER'S  TUBES.  The  illustration  shows  the  method  of  using  the  tubes  by 
coiling  them  in  a  spiral  manner  around  the  limb.  They  may  be  used  in  a  similar 
manner  in  the  case  of  the  penis. 

These    tubes    are    particularly    dangerous    on    account    of    the   intense 
cold   which   may    be    produced   by  them,   and   it   is   seldom  advisable    to 


FIG.  3A. — LEITER'S  TUBES.  This  form  is  the  best  for  use  upon  most  occasions.  The 
tubes  are  coiled  upon  and  fixed  to  a  light  flexible  metal  plate,  and  hence  are  not  likely 
to  become  kinked  or  to  leak.  The  metal  plate  is  moulded  to  the  surface  and  secured 
by  tapes,  a  fold  of  lint  being  interposed  between  it  and  the  skin. 

leave  them  on  an  acutely  inflamed  part  for  longer  than  twenty-four  hours 
at    the    outside.      The    condition    of  the   circulation    should    be    carefully 


ACUTE    INFLAMMATION.  II 

inspected  every  three  or  four  hours.  They  are  in  reality  of  more  use  in 
bleeding  or  in  great  engorgement  of  the  part  than  in  inflammation.  In 
using  them  for  inflammation,  it  will  be  found  that  water  at  a  temperature 
from  50°  to  60°  F.  is  usually  quite  sufficient. 

Heat. — Where  the  acute  inflammation  has  lasted  for  two  or  three 
days,  cold  will  no  longer  be  of  benefit ;  on  the  contrary,  it  will  be  very 
apt  to  cause  damage,  and  under  these  circumstances  it  is  best  to  resort  to 
the  application  of  heat.  The  mode  of  action  of  heat  is  somewhat  difficult 
to  explain,  but  whatever  be  the  explanation,  it  is  certain  that  it  is  a  very 
valuable  agent  in  acute  inflammation.  Where  the  process  actually  affects 
the  skin,  heat  is  not  so  generally  useful,  on  account  of  its  tendency  to 
increase  the  congestion  of  the  part,  and  in  these  cases  it  should  there- 
fore be  very  sparingly  used. 

There  are  two  methods  by  which  heat  is  usually  applied  to  the  skin 
over  an  inflamed  part,  viz.,  by  poultices  or  by  hot  fomentations.  A 
poultice  is  usually  made  with  linseed  meal  and  water,  the  proportions 
being  about  four  tablespoonfuls  of  linseed  meal  to  half  a  pint  of  water. 
Care  must  be  taken  that  the  poultice  is  not  too  heavy,  and  as  it  very 
quickly  loses  its  heat,  special  care  should  be  taken  to  see  that  the  bowl 
in  which  it  is  mixed,  and  the  material  on  which  it  is  spread,  are  well 
warmed  previous  to  use.  The  poultice  should  be  made  and  applied  as  hot 
as  the  patient  can  bear  it,  and  as  quickly  as  possible.  In  making  it, 
the  water  employed  must  be  boiling,  and  the  linseed  meal  should  be  well 
stirred  as  it  is  added,  to  prevent  the  formation  of  lumps  or  hard  masses. 
When  mixed  it  is  turned  out  upon  a  piece  of  linen  of  suitable  size,  pre- 
viously warmed,  and  large  enough  to  extend  two  inches  all  round  beyond 
the  poultice,  and  spread  with  a  small  spatula  in  an  even  layer  about  half 
an  inch  thick.  The  edges  of  the  linen  are  then  turned  up  around  the  mar- 
gins and  the  poultice  is  ready  for  use.  The  whole  operation  should  be 
carried  on  before  a  warm  fire.  In  the  case  of  superficial  inflammation  the 
poultice  is  applied  next  to  the  skin,  but  here  it  cannot  be  borne  so  hot 
as  where  the  inflammation  is  more  deeply  seated.  In  the  latter  case  it  is 
usual  to  place  a  layer  of  muslin  between  the  poultice  and  the  skin,  and  in 
this  way  a  greater  heat  can  be  tolerated.  Having  applied  the  poultice  to  the 
part,  a  layer  of  wool,  heated  before  the  fire,  is  placed  outside,  and  the 
whole  fixed  on  with  a  bandage  or  a  suitable  binder.  A  poultice  of  this 
kind  will  generally  retain  its  heat  for  about  two  hours,  and  should  then 
be  changed.  In  changing  it,  a  warm  soft  towel  should  be  at  hand,  so  that 
when  the  poultice  is  removed  the  skin  can  be  dried  and  gently  chafed 
with  the  towel,  which  is  left  in  place,  and  the  patient  again  covered  with 
blankets  till  a  fresh  poultice  is  ready  for  application.  If  this  be  not  done 
the  part  becomes  very  cold,  and  all  the  good  of  the  poultice  may  be 
undone  by  the  exposure.  Other  materials  are  used  for  poultices,  such  as 
bread  or  oatmeal,  but  if  these  materials  are  used  a  little  butter  or  oil 
should  be  added,  as  otherwise  the  poultice  is  apt  to  become  too  hard. 


12  INFLAMMATION. 

There  are  various  advantages  and  disadvantages  in  the  use  of  poultices 
as  compared  with  fomentations.  The  great  advantage  is  that  poultices 
retain  the  heat  longer,  and  therefore  it  is  not  necessary  to  change  them 
so  frequently  as  fomentations,  while,  on  the  whole,  they  are  considerably 
warmer.  The  chief  objection  arises  in  cases  where  a  surgical  operation 
will  subsequently  be  necessary.  The  proper  purification  of  the  skin  after 
a  poultice  has  been  used  is  a  difficult  matter,  for  the  latter  is  a  de- 
composing vegetable  substance,  which  soaks  into  and  penetrates  the  hair 
follicles,  the  hairs  and  the  epidermis,  and  much  scrubbing  is  required  to 
disinfect  the  skin.  Hence,  where  an  abscess  is  likely  to  form,  and  when 
surgical  measures  may  therefore  be  required,  it  is  well  to  employ  fomenta- 
tions instead  of  poultices.  With  a  view  of  obviating  this  septic  difficulty, 
various  antiseptics  have  been  mixed  with  the  poultice.  Charcoal  is  some- 
times employed,  but  this  substance  is  simply  a  deoderant,  and  possesses 
no  true  antiseptic  properties.  Boracic,  or  carbolic  acid  are  also  sometimes 
mixed  with  the  poultice.  The  best  mixture  probably  is  one  of  linseed 
meal  and  eucalyptus  oil,  but  none  of  them  are  satisfactory  from  the  anti- 
septic point  of  view,  and  hence,  where  an  operation  is  likely  to  be  re- 
quired, fomentations  should  be  substituted  for  poultices,  at  any  rate  for 
some  days  beforehand. 

In  the  case  of  fomentations,  the  rules  as  regards  the  retention  of  the 
heat  must  be  attended  to  even  more  carefully  than  in  the  case  of  poultices. 
A  fomentation  consists  of  a  piece  of  flannel  wrung  out  of  boiling  water, 
covered  with  a  piece  of  mackintosh  and  a  mass  of  wool ;  and  the  great 
point  in  the  preparation  of  a  fomentation  is  to  apply  it  as  hot  as  possible, 
and  to  prevent  the  loss  of  heat  during  its  preparation.  For  this  purpose 
it  is  well  first  of  all  to  prepare  a  mass  of  wool  considerably  larger  than 
the  flannel  and  to  place  it  in  readiness  before  a  warm  fire.  On  the  top 
of  that  place  a  piece  of  mackintosh  with  the  mackintosh  side  outwards, 
sufficiently  large  to  overlap  the  flannel  in  all  directions.  A  well-warmed 
basin  is  then  taken,  a  dry  towel  is  unfolded  and  placed  over  it,  and 
in  the  centre  of  this  towel  a  piece  of  flannel  of  suitable  size  folded  in 
two  or  four  thicknesses  is  laid.  Boiling  water  is  then  poured  over  the 
flannel,  and,  the  ends  of  the  towel  being  rapidly  twisted  up,  the  flannel 
is  squeezed  as  dry  as  possible.  No  water  must  be  left  in  the  flannel  lest 
the  patient's  skin  be  scalded.  The  folded  flannel  is  then  very  quickly 
shaken  out  and  placed  on  the  top  of  the  mackintosh,  and  then  the  whole 
mass — wool,  mackintosh,  and  flannel — are  lifted  up  and  applied  to  the  affected 
part  as  rapidly  as  possible.  As  soon  as  the  patient  can  bear  it,  the  mass 
is  fixed  on  with  a  binder  or  bandage.  The  fomentation  will  usually  require 
renewal  in  from  half  an  hour  to  an  hour,  but  it  may  be  kept  warm  longer 
by  placing  an  indiarubber  hot-water  bottle  outside  it,  if  the  patient  can  bear 
the  pressure.  The  precautions  taken  in  renewing  the  fomentations  are  the 
same  as  those  mentioned  with  regard  to  a  poultice,  that  is  to  say,  a  warm 
towel  must  be  at  hand,  with  which  the  skin  is  at  once  dried  and  chafed 


ACUTE    INFLAMMATION.  13 

when  the  fomentation  is  taken  away,  and  this  is  left  in  situ  while  the  fresh 
fomentation  is  being  prepared.  In  some  cases,  where  there  is  much  pain, 
a  considerable  amount  of  relief  may  be  afforded  by  sprinkling  on  the  surface 
of  the  fomentation,  after  it  has  been  prepared,  about  half  a  drachm  or  more 
of  laudanum,  previously  warmed  by  immersing  the  bottle  in  hot  water.  In 
other  cases  where  the  inflammation  is  deep  seated,  and  a  certain  amount 
of  irritation  of  the  skin  is  desired,  this  may  easily  be  obtained  by  sprinkling 
10  to  20  drops  of  turpentine  over  the  surface  of  the  flannel,  and  thus 
making  what  is  known  as  a  turpentine  stupe. 

A  special  material,  known  by  the  name  of  spongiopilin,  is  sold  in  order 
to  avoid  the  use  of  mackintosh  in  the  application  of  the  fomentation.  It 
consists  of  thick  felt  covered  on  one  side  with  an  impermeable  layer,  and 
this  is  employed  in  the  same  way  as  the  flannel  in  making  the  fomentation. 
As  a  rule,  however,  it  is  well  to  place  mackintosh  and  wool  outside  the 
spongiopilin,  as  in  an  ordinary  fomentation. 

General  Treatment. — The  general  treatment  of  the  patient  must  be 
directed  partly  to  the  relief  of  symptoms  such  as  pain,  and  partly  to  pro- 
moting the  excretion  of  the  poisonous  materials  absorbed  from  the  inflamed 
area  into  the  blood.  The  latter  object  is  effected  by  attempting  to  dilute 
the  poison  in  the  blood  by  means  of  diluent  drinks,  and  also  by  making 
efforts  to  assist  the  secretions  from  the  skin,  the  bowels,  and  the  kidneys. 

The  first  point  then,  in  the  case  of  inflammatory  fever,  is  to  administer 
a  purgative,  and  the  best  substance  that  one  can  use  for  that  purpose 
is  sulphate  of  magnesia  or  some  other  saline.  The  sulphate  of  magnesia 
is  given  in  a  dose  of  half  an  ounce  or  more,  dissolved  in  as  little 
water  as  the  patient  can  comfortably  swallow ;  the  more  concentrated 
it  is  the  better  is  its  effect.  By  its  means  at  least  one  copious  watery 
evacuation  a  day  should  be  ensured.  The  purge  acts  partly  by  clearing 
out  decomposing  material  from  the  intestine,  and  should  be  given  even 
though  the  bowels  have  been  previously  acting  quite  regularly.  It  acts 
partly  also  by  leading  to  transudation  of  a  quantity  of  serum  from  the 
blood,  and  thus  possibly  removing  a  quantity  of  poisonous  material.  At 
the  same  time,  the  purgative  probably  acts  also  as  a  counter-irritant,  and 
thus  exerts  a  further  beneficial  effect.  It  will  be  evident,  when  we  come 
to  speak  of  chronic  inflammation,  that  counter-irritation  is  a  very  potent 
agent  in  the  treatment,  and  it  is  probable  that  poultices  and  fomenta- 
tions act  as  counter-irritants. 

Drinks. — The  patient  should  be  encouraged  to  drink  a  large  amount 
of  fluid,  with  the  view  of  diluting  the  poison  in  the  blood,  and  of  leading 
to  its  rapid  elimination  by  the  kidneys.  Milk  should  be  given  in  large 
quantities — as  much  as  from  four  to  six  pints  a  day  if  the  patient  can 
take  it.  The  combination  of  milk  with  barley-water  is  good,  as  the  latter 
tends  to  prevent  to  some  extent  the  constipating  effects  of  the  milk.  It  also 
retards  coagulation,  and,  if  the  patient  is  much  troubled  with  the  curdling 
of  the  milk  in  the  stomach,  lime-water  may  be  added,  or  still  better,  one- 


I4  INFLAMMATION. 

half  to  one  drachm  of  the  liquor  calcis  saccharatus  to  each  tumblerful  of 
milk.  At  the  same  time,  the  patient  should  be  encouraged  to  take  fluid 
drinks  containing  bicarbonate  of  potash  or  spirit  of  nitrous  ether.  A  very 
good  one  is  that  used  in  most  hospitals,  and  called  "  imperial  drink " ; 
it  consists  of  one  to  one-and-a-half  drachms  of  cream  of  tartar  added  to 
a  pint  of  boiling  water,  and  then  allowed  to  cool,  a  little  sugar  being 
added  to  sweeten  it.  The  cream  of  tartar  may  also  be  conveniently  given 
in  gruel,  made  by  adding  a  tablespoonful  of  oatmeal  and  about  a  drachm 
of  cream  of  tartar  to  half  a  pint  of  water,  and  boiling  it,  adding  after- 
wards a  tablespoonful  of  brandy  and  a  little  sugar.  By  these  methods  the 
kidneys  are  made  to  act  without  any  undue  irritation.  Above  all  things, 
one  must  avoid  the  more  irritating  diuretics,  on  account  of  the  tendency 
that  there  is  in  many  of  these  acute  inflammatory  affections  to  albuminuria 
and  nephritis. 

Drugs. — The  congestion  may  also  be  diminished  by  slowing  the 
action  of  the  heart,  and  this  can,  to  a  certain  extent,  be  brought  about  by 
various  drugs,  notably  by  aconite.  This  drug  should  only  be  given  in 
quite  the  early  stage  of  the  inflammation,  and  then  it  often  gives  marked 
relief.  The  dose  should  be  one  minim  of  the  tincture  every  half  hour  for 
three  doses,  and  then  every  hour  for  three  or  four  more.  This  has  the 
effect  of  slowing  the  pulse,  reducing  the  temperature,  and  producing  dia- 
phoresis. The  pulse  must  be  carefully  watched  whilst  the  drug  is  being 
administered.  If  it  becomes  unduly  slow,  and  especially  if  it  shows  signs 
of  becoming  weak  or  irregular,  the  aconite  should  be  stopped  at  once,  and 
if  the  weakness  and  irregularity  are  very  marked,  a  hundredth  of  a  grain  of 
digitaline  should  be  injected  subcutaneously,  and  repeated  in  an  hour  or 
two  if  necessary.  In  the  case,  for  example,  of  an  initial  pulse  rate  of  no, 
a  reduction  to  a  rate  of  80  is  as  much  as  is  desirable. 

At  night  time,  a  Dover's  powder  may  be  given,  partly  with  a  view  of 
obtaining  sleep  and  freedom  from  pain,  but  mainly  to  promote  the  action 
of  the  skin.  The  latter  object  may  also  be  furthered  by  giving  liquor 
ammoniae  acetatis  in  two  to  four  drachm  doses  every  three  or  four  hours. 

The  food  should  consist  entirely  of  fluid,  essentially  of  milk,  with 
occasionally  a  certain  amount  of  beef-tea ;  and,  as  the  patient  is  apt  to 
neglect  to  take  a  proper  amount  of  nourishment,  it  is  well  to  arrange 
for  the  administration  of  food  about  every  two  hours — a  tumblerful  of 
milk  alternating  with  a  cup  of  beef-tea  or  some  Valentine's  meat  extract. 
During  the  period  of  recovery  from  the  inflammatory  condition,  nourishing 
diet,  with  stimulants  and  tonics,  more  especially  iron,  should  of  course  be 
given. 

PROGNOSIS. — The  prognosis  of  acute  inflammation  depends  on  its 
nature  and  seat.  Should  an  acute  inflammation,  of  the  degree  of  which 
we  have  been  speaking,  last  for  more  than  three  or  four  days,  suppuration 
will  almost  certainly  take  place.  If,  on  the  other  hand,  the  inflammation 
is  subsiding,  wrinkling  of  the  skin  is  noticed,  and  a  favourable  prognosis  as 


CHRONIC   INFLAMMATION.  !5 

regards  the  question  of  suppuration  may  in  most  cases  be  given,  although 
sometimes,  where  an  abscess  has  formed,  wrinkling  of  the  skin  in  its 
vicinity  may  be  present,  owing  to  the  subsidence  of  the  oedema. 


CHRONIC   INFLAMMATION. 

NATURE. — Chronic  inflammation  may  either  begin  as  an  acute  process, 
in  which  the  symptoms  do  not  entirely  disappear  but  gradually  become 
much  less  acute  and  pass  slowly  into  the  chronic  form,  or,  as  perhaps  more 
often  happens,  it  is  not  preceded  by  the  acuter  form,  but  is  chronic  from 
the  first.  The  process  of  chronic  inflammation  is  somewhat  difficult  to 
understand  and  explain,  because  it  generally  forms  part  of  some  other 
morbid  process,  and  it  is  not  easy  to  separate  one  from  the  other. 

CAUSES. — Like  acute  inflammation,  the  chronic  form  depends  upon 
the  continued  action  of  some  exciting  cause,  but  the  causes  which  produce 
chronic  inflammation  are  not  of  the  same  violent  nature  as  those  which 
set  up  the  acute  inflammation  with  which  we  have  already  dealt.  Among 
the  causes  of  chronic  inflammation  may  be  mentioned  the  presence  of 
a  foreign  body.  For  example,  a  bullet  embedded  in  the  tissues,  pro- 
vided that  it  has  not  carried  in  with  it  any  pyogenic  material,  will  set  up 
chronic  inflammation  in  the  part,  which  may  last  for  a  considerable  time 
after  the  lodgment  of  the  foreign  body.  Any  obstruction  to  the  free  exit 
of  secretion  from  a  gland,  as  for  instance  a  stricture  or  a  calculus  in  its 
duct,  brings  about  retention  of  the  secretion  behind  the  obstruction,  and 
this  leads  to  a  condition  of  chronic  inflammation  in  the  gland,  which  will 
continue  until  the  obstruction  is  relieved,  or  until  the  gland  undergoes 
atrophy.  Chronic  inflammation  not  infrequently  results  also  from  pressure, 
and  ends  in  the  formation  of  a  quantity  of  new  tissue,  as  is  seen  for 
example  in  callosities,  which,  forming  in  a  part,  subject  it  to  much  pres- 
sure. Then,  again,  various  deposits  from  the  blood  are  responsible  for 
exciting  a  state  of  chronic  inflammation ;  for  example,  in  gout  the  deposi- 
tion of  urates  in  the  tissues  keeps  up  a  condition  of  chronic  inflammation 
in  the  neighbourhood  of  the  deposit.  In  some  cases,  chronic  inflammation 
seems  to  be  dependent  on  certain  states  of  the  blood,  the  precise  nature 
of  which  we  do  not  exactly  understand  ;  as,  for  example,  in  rheumatism, 
where  chronic  inflammation  of  fibrous  tissues  very  often  occurs,  and  may 
continue  for  a  long  time.  Perhaps  the  most  common  cause  of  chronic 
inflammation  is  the  presence  in  the  tissues  of  some  morbid  material,  more 
especially  the  specific  virus  of  one  of  the  chronic  infective  diseases,  notably 
tubercle  and  syphilis,  and  it  is  well  to  bear  in  mind  that  in  these  cases, 
especially  in  tubercle,  the  main  part  of  the  swelling  in  the  area  affected  is 
due,  not  to  the  mass  of  tuberculous  tissue,  but  to  the  chronic  inflammation 
which  its  presence  has  set  up. 

CHANGES  IN  THE  TISSUES.— The  result  of  chronic  inflammation 
is  that  a  large  amount  of  new  connective  tissue  is  formed.  The  part  becomes 


16  INFLAMMATION. 

full  of  cells,  many  of  which  are  undergoing  transition  into  fibrous  tissue, 
and  with  the  cells  there  are,  at  the  more  recent  points,  young  blood  vessels 
in  large  numbers.  A  chronically  inflamed  tissue,  of  itself,  never  undergoes 
suppuration.  If  so-called  suppuration  occur  in  a  part  which  is  the  seat 
of  chronic  inflammation,  it  is  due  either  to  acute  septic  infection,  or  to  the 
breaking  down  of  the  morbid  material  which  is  causing  the  inflammation ; 
this  is  especially  the  case  in  tubercle.  A  typical  chronic  abscess,  which 
has  not  been  acute  at  the  commencement,  is  practically  always  tuberculous. 

SYMPTOMS. — Of  the  symptoms  of  chronic  inflammation,  the  most 
characteristic  is  the  presence  of  swelling,  which  is  due  to  the  formation  of 
a  large  amount  of  new  connective  tissue.  For  example,  a  bone  which  is 
the  seat  of  chronic  inflammation  may  become  enormously  thickened.  In 
certain  organs  where  there  is  much  soft  tissue,  as  in  the  liver,  the  final 
result  of  a  chronic  inflammation  may  be  actual  diminution  in  the  size  of 
the  part,  the  large  amount  of  new  connective  tissue  formed  in  it  undergoing 
contraction,  and  leading  to  atrophy  of  the  normal  cells.  In  most  cases, 
however,  swelling  is  a  prominent  feature.  Of  the  other  symptoms,  the 
pain  varies  with  the  situation  and  is  often  but  slight,  although  in  bone  it 
is  a  very  marked  feature,  owing  to  the  compression  of  the  nerves  by  the 
exudation  in  the  unyielding  tissues.  A  certain  amount  of  tenderness  and 
heat  are  almost  always  present.  The  increased  vascularity  of  the  tissue  is 
often  evidenced  by  the  enlargement  of  the  veins  on  the  surface,  large  dilated 
vessels  running  over  the  swollen  part.  Constitutional  symptoms  are  not 
present  as  a  rule.  If  they  are,  it  is  either  because  some  vital  organ  is 
affected,  or  else  they  are  due  to  the  disease  which  is  setting  up  the 
inflammation. 

TREATMENT. — In  considering  the  treatment  of  chronic  inflammation, 
the  first  point  is  to  ascertain  whether  or  not  we  can  remove  the  cause,  for 
if  this  be  effectually  done,  the  inflammation  will  at  once  subside.  Thus, 
in  cases  where  a  foreign  body,  such  as  a  bullet,  is  embedded  in  the  tissues, 
the  indication  is  to  cut  down  on  and  remove  it.  Similarly,  where  the  chronic 
inflammation  is  caused  by  obstruction  of  a  duct,  this  must  be  remedied  ; 
where  it  is  due  to  a  deposit  from  the  blood,  as  in  gout,  or  to  some  state 
of  the  blood,  as  in  rheumatism,  appropriate  medicinal  treatment  must  be 
adopted  for  the  elimination  of  the  noxious  material  from  the  circulation. 
Most  commonly,  however,  as  has  already  been  said,  the  cause  of  the 
inflammation  is  the  presence  of  some  chronic  infective  disease,  and  it  is 
not  always  easy  to  get  rid  of  this  completely,  more  especially  where  it  is 
of  a  tuberculous  nature.  Where  it  is  not  possible  or  advisable  to  remove 
the  cause,  the  treatment  consists  in  taking  various  measures  which  are 
calculated  to  diminish  the  inflammation,  and  these  measures  are  essen- 
tially local. 

Local  Treatment. — Kest. — The  first  essential  point  in  the  local  treat- 
ment, after  the  question  of  removal  of  the  primary  cause,  is  to  secure 
complete  physiological  rest  of  the  part,  and  this  is  absolutely  necessary 


CHRONIC    INFLAMMATION.  i-j 

for  the  subsidence  of  the  inflammation.  If  the  seat  of  the  inflammation  be 
a  joint,  it  should  be  fixed ;  if  it  be  any  part  affected  by  muscular  move- 
ments, rest  must  also  be  obtained,  and  always,  if  possible,  in  bed  or  in 
an  elevated  position.  It  has  already  been  pointed  out,  with  regard  to 
acute  inflammation,  that  the  position  of  the  part  affects  the  congestion,  and 
in  chronic  inflammation  also,  the  relief  of  the  congestion  by  the  adoption 
of  the  elevated  position  is  a  very  essential  element  in  the  treatment. 
Even  although  it  may  be  impossible  to  remove  the  exciting  cause  (e.g. 
tubercle),  much  good  may  be  done  by  taking  steps  to  dimmish  the 
inflammation  itself,  because  inflamed  tissues  are  more  easily  invaded  by 
the  morbid  process  than  healthy  ones,  and  if  this  condition  of  chronic 
inflammation  be  diminished,  the  extension  of  the  primary  disease  may  thereby 
be  checked. 

In  addition  to  rest,  there  are  various  other  measures  which  are  employed, 
of  which  perhaps  the  most  important  is  counter-irritation.  By  counter- 
irritation  is  meant  the  application  of  an  irritant  to  some  superficial  part 
of  the  body,  usually  to  the  skin,  either  over  the  seat  of  the  inflammation 
or  at  a  little  distance  from  it,  more  especially  to  a  part  which  is  in 
intimate  nervous  connection  with  the  inflamed  area.  Exactly  how  benefit 
results  from  the  use  of  irritation  of  the  skin  is  not  at  all  evident ;  we  can 
only  suppose  that  the  irritant  acts  in  some  way  through  the  nervous 
system.  As  has  already  been  mentioned  in  speaking  of  acute  inflammation, 
the  poultices  and  fomentations  which  are  of  such  value  there  probably 
owe  their  virtue  partly  to  the  principle  of  counter-irritation,  and  they  may 
be  classed  as  the  mildest  counter-irritants  with  which  we  are  acquainted. 
In  cases  of  chronic  inflammation,  however,  some  more  active  agent  is 
usually  necessary. 

Of  the  counter-irritants  most  commonly  employed,  we  shall  refer  to 
mustard,  iodine,  blisters,  and  the  actual  cautery.  Of  these,  mustard  is 
the  mildest,  and  is  employed  either  in  the  form  of  mustard  leaves  or  as 
a  plaster.  The  mustard  leaves,  which  only  require  damping  before  being 
applied,  are  very  handy  and  cleanly,  and  are  generally  used  when  the 
effect  of  counter-irritation  alone  is  required.  As  a  substitute  for  them, 
the  ordinary  mustard  plaster,  made  by  mixing  mustard  with  tepid  water 
into  a  thick  paste  and  spreading  the  mass  thus  obtained  on  a  piece  of 
linen  or  brown  paper,  may  be  employed.  In  using  either  of  these  pre- 
parations, the  guide  to  the  length  of  time  that  they  should  be  left  on  is 
the  patient's  sensations.  Generally  they  will  require  removal  in  from  ten 
to  twenty  minutes ;  if  left  on  longer  than  that  they  are  apt  to  blister,  and 
special  care  should  be  taken  not  to  leave  them  on  too  long  in  the  case 
of  young  children,  in  whom  they  may  produce  actual  sloughing.  If,  in 
addition  to  the  counter-irritation,  the  warm  poultice  action  be  also  required, 
a  mustard  and  linseed  poultice  may  be  employed.  The  simplest  plan  is 
to  make  the  poultice  with  boiling  water  in  the  ordinary  way  (see  p.  n), 
using  one  part  of  mustard  to  four  parts  of  linseed  meal.  If  a  still  more 

B 


1 8  INFLAMMATION. 

energetic  action  be  required,  an  ordinary  linseed  poultice  is  made,  and 
over  the  surface  of  it  mustard  is  thickly  dusted,  and  the  poultice  then 
put  on. 

The  most  popular  method  of  counter-irritation  is  the  use  of  tincture  of 
iodine  or  of  linimentum  iodi,  the  part  being  painted  with  the  iodine  every 
day  until  the  skin  becomes  so  sore  that  the  patient  cannot  go  on  with  it. 
As  a  rule,  however,  the  effects  of  iodine  are  not  satisfactory,  and  in  many 
cases  of  tuberculous  glands,  in  which  it  is  so  commonly  used,  it  is  positively 
harmful,  as  it  tends  to  bring  about  suppuration.  The  two  most  potent 
methods  for  producing  smart  counter-irritation  are  blisters  and  the  actual 
cautery. 

Blisters  may  be  produced  either  by  the  use  of  the  ordinary  emplastrum 
lyttae  of  the  Pharmacopoeia,  or  by  means  of  the  liquor  epispasticus. 
Before  applying  them  the  part  should  be  thoroughly  cleaned,  and  if  there 
are  hairs  they  should  be  shaved  off.  In  the  case  of  adults  the  plaster 
should  be  left  on  for  about  ten  hours.  The  length  of  time  which  it  will 
require  to  produce  its  effect  varies,  however,  with  the  thickness  of  the  skin. 
In  parts  where  the  skin  is  thin,  or  in  the  case  of  children,  a  considerably 
shorter  time — about  five  or  six  hours — will  generally  be  sufficient ;  on 
the  other  hand,  where  the  skin  is  thick,  as  on  the  palm  of  the  hand  or 
the  sole  of  the  foot,  the  blister  may  even  require  twenty-four  hours  in 
order  to  rise.  After  the  plaster  is  removed,  the  part  is  generally  the  seat 
of  a  good-sized  blister.  Sometimes,  however,  the  skin  is  merely  reddened, 
or  at  most  one  or  two  small  vesicles  only  are  present;  the  subsequent 
application  of  a  fomentation  or  a  poultice  will  ensure  the  proper  rising  of 
the  blister.  If,  however,  it  does  not  rise  properly  in  the  course  of  a  few 
hours,  painting  the  skin  with  the  liquor  epispasticus  and  allowing  it  to  dry 
will  usually  produce  a  satisfactory  result.  Some  prefer  the  liquor  epispasticus 
alone,  painting  it  over  the  part  and  allowing  it  to  dry  two  or  three  times 
in  succession.  It  must  be  freshly  prepared,  as  otherwise  it  is  very  uncer 
tain  in  its  action.  The  effect  of  the  fluid  may  often  be  increased  by  rubbing 
a  drop  or  two  of  croton  oil  over  the  surface  before  application. 

Precautions. — Besides  taking  care  not  to  leave  the  plaster  on  too  long 
for  fear  of  causing  sloughing  of  the  skin,  we  must  bear  in  mind  the  danger 
that  the  patient  runs  of  absorbing  the  drug,  in  which  case  there  is  con- 
siderable risk  of  nephritis.  Blisters  should  not,  therefore,  be  applied  over 
large  areas  where  the  skin  is  delicate,  and  should  not  be  used  at  all  where 
there  is  any  renal  disease.  As  to  the  best  position  for  applying  the  blister, 
it  is  well,  where  the  inflammation  is  still  active  and  is  affecting  the  skin 
or  the  subcutaneous  tissues,  not  to  apply  it  immediately  over  the  seat  of 
disease,  as  otherwise  it  would  probably  increase  the  congestion  of  the  part, 
and  thus  augment  the  inflammation.  It  is  better  in  these  cases  to  apply 
it  at  a  little  distance  away.  Where  the  inflammation  is  subsiding,  however, 
there  is  not  the  same  objection  to  applying  it  directly  over  the  affected 
area;  on  the  contrary,  the  increased  flow  of  blood  and  lymph  which  is 


CHRONIC    INFLAMMATION. 


19 


thus  set  up  may,  so  to  speak,  wash  out  the  part  and  aid  the  absorption. 
Where  the  inflammation  is  more  deeply  seated,  the  best  effect  is  usually 
produced  by  applying  the  blister  directly  over  the  spot. 

The  actual  cautery  is  one  of  the  most  potent  means  of  producing 
counter-irritation,  and  it  is  used  either  to  form  one  large  sore  or  a  number 
of  small  ones.  The  formation  of  a  large  sore  is  probably  the  more  effectual 
method.  In  cases  of  spinal  disease,  for  example,  the  production  of  a 
superficial  sore  on  each  side  of  the  spine,  two  or  three  inches  in  length 
and  a  couple  of  inches  in  breadth,  will  often  do  a  great  deal  of  good. 
Similarly,  in  hip-joint  disease,  two  sores,  one  in  front  and  one  behind  the 
joint,  will  often  relieve  the  acute  starting  pains  from  which  the  patient 
suffers.  Only  the  superficial  part  of  the  skin  should  be  acted  on,  as  it  is 
important  that  the  whole  thickness  should  not  be  destroyed.  In  order  to 


FIG.  4. — FLAT  CAUTERY.     The  flat  surface  is  generally  used,  but  the  edge  can  be 
employed  if  it  be  desired  to  score  lines  upon  the  skin. 

produce  these  large  sores  effectually,  and  without  too  much  destruction  of 
tissue,  it  is  best  to  use  a  flat,  iron  cautery — such  as  that  depicted  above 
(see  Fig.  4) — heated  to  a  white  heat,  and  for  this  an  anaesthetic  is  generally 
necessary.  If  not  at  a  white  heat,  it  is  difficult  to  gauge  the  amount  of 
destruction  of  the  skin  produced ;  one  may  easily  do  either  too  much  or 
too  little.  As  a  matter  of  experience  we  know  that,  where  a  cautery  is 
used  white  hot,  it  suffices  to  rub  it  quickly  two  or  three  times  over  the 
part  in  order  to  produce  the  desired  amount  of  burning.  All  that  is 
wanted  is  to  destroy  the  epidermis  and  portions  of  the  rete  mucosum,  and 
thus  lay  bare  the  terminations  of  a  large  number  of  nerves.  After  the 
cautery  has  been  applied,  poultices  or  hot  fomentations  should  be  used 
until  the  slough  separates,  which  will  occur  in  four  or  five  days.  If  now 
the  wound  were  left  to  itself,  or  merely  dressed  with  some  simple  ointment, 
it  would  heal  with  great  rapidity,  because  the  skin,  not  being  deeply 
destroyed,  there  are  numerous  points  from  which  epithelium  would  quickly 
spread  over  the  part.  As  a  matter  of  fact,  however,  it  is  necessary,  in 
order  to  get  the  best  effect  from  the  use  of  the  actual  cautery,  to  keep 
the  sore  open  from  four  to  six  weeks.  This  can  only  be  done  by  the 
application  of  some  irritant  ointment  to  the  sore  after  the  slough  has 
separated.  The  ointment  usually  employed  for  this  purpose  is  savin  oint- 
ment, but  many  patients  are  unable  to  bear,  for  any  length  of  time,  the 
pain  caused  by  the  pure  savin  ointment,  and  hence  in  most  cases  it  is 
necessary  to  dilute  it  with  an  equal  part  of  simple  ointment,  or  to  add 
about  10  per  cent,  of  cocaine.  Even  where  savin  ointment  is  used  healing 


20  INFLAMMATION. 

often  occurs  too  rapidly,  and  if  this  be  the  case  it  may  be  necessary 
to  destroy  the  young  epithelium  on  the  surface  of  the  sore  from  time 
to  time  with  nitrate  of  silver,  or,  if  that  does  not  suffice,  to  apply  potassa 
fusa.  If  this  latter  application  is  required,  a  stick  of  potassa  fusa  is  held 
in  a  pair  of  forceps  and  quickly  rubbed  over  the  part,  which  is  then  covered 
with  lint  steeped  in  vinegar.  In  many  cases  where  much  pain  is  present 
it  is  remarkable  how  quickly  it  disappears  after  the  application  of  the 
cautery,  and  how,  if  the  wound  be  allowed  to  heal  too  rapidly,  the  pain  will 
at  once  recur. 

Another  form  of  cautery  is  that  known   as    Corrigaris  cautery,    or  the 
button   cautery   (see  Fig.  5).     This  is  a  small,  round,   metal  button  fixed 


FIG.  5. — CORRIGAN'S  CAUTERY  AND  PORTABLE  SPIRIT  LAMP  FOR  HEATING. 

in  a  handle,  and  is  also  heated  to  a  white  heat  and  pressed  for  a  moment 
on  the  part  which  is  to  be  burned,  and  by  its  means  a  number  of  little 
sores  are  produced.  Where  the  proper  cautery  is  not  at  hand,  the 
same  effect  can  be  produced  by  the  broad  blade  of  a  Paquelin's  cautery. 
An  anaesthetic  is  not,  as  a  rule,  necessary  in  this  case.  The  effect  is  not 
so  good,  at  any  rate  in  extensive  inflammation  of  bone,  as  where  the  larger 
cautery  is  employed. 

In  former  times  a  variety  of  other  methods  were  used  for  the  production 
of  counter-irritation;  for  instance,  croton  oil  was  rubbed  over  the  part, 
either  alone  or  in  the  form  of  a  liniment  consisting  of  one  part  to  eight 
of  oil.  This  was  used  chiefly  in  chest  cases,  and  the  result  of  such  an  appli- 
cation is  the  production  of  a  pustular  eruption.  Tartar  emetic  ointment, 
in  a  strength  of  one  to  five  of  simple  ointment,  acts  in  a  similar  manner 
and  causes  a  pustular  eruption.  Setons  were  also  formerly  much  used, 
that  is  to  say,  a  piece  of  silk  or  worsted  threaded  upon  a  suitable  needle 
was  passed  through  the  skin  and  left  there  after  the  needle  had  been 
cut  off,  the  result  being  that  a  suppurating  sinus  formed,  which  could 
be  kept  open  for  any  length  of  time.  The  objection  to  the  use  of  the 
seton  is  that  a  septic  wound  is  produced  which  may  seriously  injure  the 
patient,  and  may  be  the  starting  point  of  one  of  the  acute  septic  diseases. 

There  still  remain  two  other  methods  of  great  value  in  the  treatment 
of  chronic  inflammation  which  require  mention.  The  first  of  these  is  free 
incision  into  the  part,  and  this  in  many  cases  is  of  the  utmost  value 
For  example,  in  chronic  inflammation  of  the  periosteum  there  is  nothing 


CHRONIC    INFLAMMATION.  21 

that  relieves  the  pain  and  improves  the  condition  so  much  as  a  free 
incision,  which  should  of  course  be  made  aseptically.  The  effect  of  this 
is  much  increased  if  a  portion  of  the  thickened  periosteum  is  also 
taken  away.  Similarly,  in  chronic  osteitis  the  best  method  of  treatment 
is  to  gouge  away  a  large  portion  of  the  inflamed  bone,  even  although  the 
whole  of  the  area  affected  be  not  removed.  The  rest  very  soon  improves, 
and  the  patient  is  much  relieved,  and  often  cured.  From  the  point  of 
view  of  diagnosis,  also,  it  is  of  much  importance  to  bear  in  mind  the  great 
value  of  free  incisions  as  a  curative  agent  in  cases  of  chronic  inflamma- 
tion, because  in  many  cases  it  is  difficult  to  be  certain  whether  one  has 
to  deal  with  a  chronic  inflammation  or  a  tumour.  Knowing,  however, 
that  free  incision  into  a  chronically  inflamed  part  is  one  of  the  best 
means  of  treating  the  inflammation,  one  need  not  hesitate  to  ascertain  at 
once  the  state  of  matters  by  making  a  free  incision  into  the  part.  If  it 
turns  out  that  we  have  a  tumour  to  deal  with,  the  diagnosis  is  made,  and 
the  surgeon  can  then  proceed  to  treat  the  case  as  is  required.  If,  on  the 
other  hand,  the  case  proves  to  be  one  of  chronic  inflammation,  the  very 
best  thing  has  been  done  to  cure  the  patient. 

Pressure  is  also  a  good  deal  employed  in  cases  of  chronic  inflamma- 
tion, but  it  is  mainly  of  value  when  the  process  is  subsiding.  If  much 
pressure  be  applied  to  a  part  in  which  active  inflammation  is  going  on,  it 
is  very  apt  to  increase  the  latter  instead  of  diminishing  it.  But  where 
the  inflammation  is  subsiding,  pressure  is  one  of  the  very  best  means  to 
employ.  For  example,  in  cases  of  thickening  of  the  epididymis  after  acute 
epididymitis,  strapping  the  testicle  is  the  favourite  and  best  method  of 
treatment.  Pressure  is  also  a  good  deal  used  in  cases  of  chronic  inflam- 
mation of  joints,  whether  dependent  on  tuberculosis  or  not,  and  it  may  be 
carried  out  in  various  ways,  the  essential  point  being  that  the  pressure 
should  be  equable  and  not  too  great.  Perhaps  the  best  way  to  obtain 
firm,  equable  pressure  is  to  surround  the  part  with  a  large  mass  of  cotton 
wool  or  silk  waste  in  even  sheets  or  layers,  without  any  lumps  or  irregu- 
larities, and  then  to  apply  a  bandage  over  it  as  tightly  as  possible.  To 
prevent  the  bandage  becoming  loose  afterwards,  some  starch  or  silicate  of 
soda  solution  should  be  rubbed  into  it.  This  method  will  be  referred 
to  more  particularly  when  we  come  to  speak  of  joint  diseases.  In  some 
cases  an  elastic  bandage  is  applied  outside  the  wool,  but  if  this  be  done 
it  must  not  be  put  on  too  tightly,  for  the  elasticity  multiplies  the  force 
considerably.  Another  way  in  which  pressure  is  applied,  especially  in 
joint  diseases,  is  by  means  of  Scott's  dressing,  in  which  we  have  a  com- 
bination of  pressure  and  counter-irritation.  Scott's  dressing  consists  of  the 
compound  mercury  ointment  (imguentum  hydrargyri  co)  spread  upon  chamois 
leather.  The  chamois  leather  is  cut  into  strips  and  applied,  like  other  forms 
of  strapping,  in  imbricated  layers  around  the  diseased  part,  the  application 
being  made  quite  firmly.  Outside  this  a  layer  of  cotton  wool  and  a  firm 
bandage  are  applied,  and  the  limb  placed  on  a  splint.  Another  method 


22  INFLAMMATION. 

of  applying  Scott's  dressing  is  to  spread  the  ointment  upon  a  sufficiently 
large  piece  of  lint,  cut  this  into  strips,  and  apply  them  to  the  limb  in  the 
usual  imbricated  layers.  Outside  these,  ordinary  strapping  is  applied  in  a 
similar  manner.  A  splint  is  not  always  necessary.  The  part  should  be 
shaved  before  the  strapping  is  applied,  and  the  dressing  should  be  renewed 
every  four  or  five  days,  both  because  the  skin  is  apt  to  become  raw,  and 
also  because  the  strapping  slips  and  the  dressing  becomes  loose. 

Lastly,  we  have  to  consider  massage  in  relation  to  chronic  inflammation. 
Massage  is  chiefly  of  value  where  the  inflammation  has  come  more  or  less 
to  a  standstill,  and  where  it  is  a  question  of  causing  absorption  of  the 
inflammatory  products.  If  employed  during  the  active  stage  it  is  apt  to 
make  matters  worse.  The  essential  principles  of  massage  are,  in  the  first 
place,  to  break  up  the  products  of  the  chronic  inflammation,  and,  in  the 
second  place,  to  promote  the  absorption  of  the  broken  up  materials  by  the 
lymphatic  vessels.  Various  actions  are  employed  with  the  view  of  breaking 
up  the  new  material.  The  mildest  form  is  what  is  termed  "  friction  mas- 
sage," that  is  to  say,  with  two  or  three  fingers  of  one  hand  the  part  is 
rubbed  in  a  circular  manner  for  some  time,  in  order  to  break  up  the 
exudation,  and  then  the  material  is  forced  into  the  lymphatic  vessels  by  an 
upward  and  more  uniform  pressure,  which  is  called  "effleurage."  In  effleu- 
rage,  the  part  which  has  been  subjected  to  the  friction  is  grasped  with  the 
whole  hand,  more  especially  between  the  thenar  and  hypothenar  eminences, 
and  is  firmly  and  gently  squeezed  in  an  upward  direction.  This  is  repeated 
a  good  many  times,  and  then  again  the  friction  is  resumed,  and  again  the 
effleurage  follows.  Where  the  material  is  more  difficult  to  break  up,  another 
action,  called  "  petrissage "  or  firm  kneading  of  the  part,  is  resorted  to. 
The  part  is  grasped  between  the  fingers  and  the  thumb,  and  is  firmly 
kneaded,  and  then,  following  the  kneading,  the  broken  up  products  are  forced 
into  the  lymphatics  by  the  action  of  effleurage.  Lastly,  where  the  material 
is  still  more  dense,  and  more  especially  where  it  is  limited  to  a  small  area, 
the  action  of  "  tapotement "  is  employed,  that  is  to  say,  the  part  is  firmly 
tapped,  either  with  the  fingers  or  a  special  instrument,  and,  after  repeated 
and  violent  tappings  as  hard  as  the  patient  can  bear,  effleurage  is  again 
carried  out.  At  first,  massage  should  be  very  gentle,  but,  as  the  patient 
becomes  accustomed  to  it,  the  more  forcible  measures  may  be  adopted. 
As  a  rule,  a  sitting  of  twenty  minutes  once  a  day  is  sufficient,  but  after 
three  or  four  days,  if  distinct  benefit  results,  there  may  be  two  sittings  daily, 
morning  and  evening,  and  as  time  goes  on  the  length  of  the  sittings  may 
be  increased  to  three-quarters  of  an  hour  or  an  hour  at  a  time.  The 
length  of  time  required  for  a  cure,  of  course,  entirely  depends  on  the  nature 
of  the  case  and  the  progress  made :  except  in  extensive  and  obstinate 
cases,  three  weeks  generally  suffice.  Massage  is  especially  useful  after 
inflammation  which  causes  adhesion  either  between  muscles,  or  between 
tendons  and  their  sheaths,  or  in  joints  or  wherever  much  thickening  is  left 
after  inflammation  or  injury. 


CHRONIC    INFLAMMATION.  23 

General  Treatment. — The  constitutional  treatment  in  chronic  inflamma- 
tion will  depend  rather  on  the  disease  which  is  at  the  bottom  of  the 
process  than  on  the  process  itself.  It  is  of  course  very  essential  that  the 
patient  should  be  put  under  the  best  possible  hygienic  conditions,  and  that 
he  should  have  plenty  of  fresh  air.  Food  of  the  most  nourishing  character 
should  be  ordered,  and,  in  cases  where  the  patient  is  weakly,  stimulants 
should  be  administered.  As  regards  medicines,  the  usual  remedies  for 
gout,  rheumatism,  syphilis,  etc.,  may  be  employed  as  required.  Even  in 
some  cases  not  due  to  syphilis,  iodide  of  potassium  and  mercury  are 
administered  in  small  doses,  but  as  a  rule  these  do  not  then  produce  any 
marked  effect. 

To  sum  up,  therefore,  we  have  the  following  means  at  our  disposal  in 
the  treatment  of  chronic  inflammation,  viz.  :  the  removal,  or  at  least  the 
appropriate  treatment,  of  the  cause;  then  rest,  position,  counter-irritation, 
free  incisions,  pressure,  massage,  and  general  treatment.  Of  these  latter, 
rest,  position,  and  good  hygiene  and  nourishing  food  are  essential  in  all 
cases.  Of  the  various  other  methods  free  incisions,  made  aseptically,  are 
the  most  certain  and  speedy,  but  in  many  cases  they  may  not  be  necessary 
or  advisable.  Under  such  circumstances,  resort  may  be  had  to  counter- 
irritation,  or,  if  the  inflammation  is  not  very  active,  to  the  use  of  pressure. 
In  very  inactive  cases,  or  during  subsidence  of  the  trouble,  pressure  and 
massage  are  of  great  value. 


CHAPTER    II. 

ACUTE  SUPPURATION. 

DEFINITION. — By  acute  suppuration  is  meant  a  process  where  the 
inflammation,  after  reaching  the  stage  of  granulation,  goes  on  to  liquefaction 
of  the  tissues  and  the  formation  of  pus.  Pus  is  a  fluid  containing  in 
suspension  cells  resembling  leucocytes,  and  it  may  either  form  in  the 
substance  of  the  tissues  where  the  inflammation  is  deep-seated,  or  be  given 
off  from  a  free  surface.  We  shall  only  consider  here  the  question  of 
suppuration  as  it  occurs  in  the  substance  of  the  tissues.  Suppuration  from 
a  free  surface  will  be  discussed  later,  in  connection  with  the  treatment  of 
wounds  and  ulcers. 

SUPPURATION  IN  THE  TISSUES.— Suppuration  in  the  tissues 
occurs  under  two  forms.  In  the  first,  the  pus  is  contained  in  a  well-defined 
cavity  with  a  distinct  wall  formed  of  granulation  tissue ;  in  the  second,  it 
infiltrates  the  cellular  tissue  and  there  is  no  proper  limiting  membrane, 
the  tissues  being,  so  to  speak,  soaked  with  the  purulent  material.  The 
former  is  the  ordinary  circumscribed  acute  abscess,  the  latter  is  a  much 
more  dangerous  form  of  suppuration,  and  is  known  as  diffuse  cellulitis. 

Causes. — Acute  suppuration  is  always  due  to  the  pyogenic  organisms, 
the  circumscribed  abscess  being  more  especially  caused  by  the  staphylococcus 
pyogenes  aureus  or  albus  (and  in  some  rare  instances  by  other  less  virulent 
forms),  diffuse  cellulitis  by  the  streptococcus  pyogenes.  Although  these 
organisms  are  the  essential  cause  of  acute  suppuration,  it  must  be  borne 
in  mind  that  they  will  not  necessarily  of  themselves  cause  suppuration 
unless  present  in  large  numbers  or  in  a  state  of  extreme  virulence.  In  most 
cases  other  accessory  factors  which  favour  the  growth  of  the  organisms 
are  present,  as,  for  example,  conditions  which  enable  the  organisms  to  rest 
in  the  part,  or  which  produce  a  weak  spot  in  which  the  tissues  are  less 
resistent  than  elsewhere.  Thus,  it  is  not  uncommon  to  find  acute  abscesses 
forming  in  parts  which  have  been  injured,  or  have  previously  been  the  seat 
of  inflammation,  the  tissues  there  being  in  a  weak  state  and  less  able 
to  resist  the  attack  of  the  parasite.  The  organisms  reach  the  part  either 
directly  through  a  wound,  or  indirectly  through  the  lymphatic  vessels  or 
the  blood  stream.  Usually,  in  the  case  of  an  acute  abscess  the  entrance  is 
more  or  less  direct.  The  organisms  may  gain  entrance  to  the  blood  either 


CIRCUMSCRIBED   ACUTE   ABSCESS.  25 

through  wounds,  or  they  may  pass  through  an  unbroken  surface  which  is  no 
longer  quite  healthy.  This  is  more  especially  the  case  with  the  intestinal 
mucous  membrane,  and  it  is  not  uncommon,  in  cases  of  acute  suppurative 
periostitis  or  osteomyelitis,  to  obtain  a  history  of  diarrhoea  or  some  other 
intestinal  derangement  immediately  preceding  the  onset  of  the  trouble. 

Circumscribed  Acute  Abscess— Symptoms.— When  an  acute  in- 
flammation which  has  gone  on  to  granulation  has  lasted  for  four  or  five 
days,  it  is  almost  certain  that  suppuration  will  occur.  When  this  takes 
place,  the  centre  of  the  brawny  swelling  softens,  and  fluctuation  can  very 
soon  be  detected.  Where  the  abscess  is  subcutaneous,  the  skin  ultimately 
gives  way  over  the  soft  spot,  and  pus  escapes.  Where  the  abscess  is 
deep-seated,  the  presence  of  pus  may  not  be  easily  recognized  at  an  early 
period,  but  when  the  acute  symptoms  have  lasted  for  several  days  and 
there  is  cedema  of  the  skin  over  the  part,  this  is  generally  sufficient 
indication  of  the  presence  of  pus. 

Mode  of  Extension. — When  an  acute  abscess  has  formed,  it  spreads 
along  the  tissues  which  possess  the  greatest  vitality,  the  extension  not 
being  a  mechanical  process  due  to  the  pressure  of  the  pus,  but  an 
active  and  vital  one.  This  is  what  is  known  as  the  "  burrowing "  of 
the  abscess.  Where  an  abscess  forms  beneath  the  skin,  it  spreads  to  this 
structure,  as  the  skin  is  the  tissue  in  which  the  vital  processes  are  most 
active,  and  it  ultimately  bursts  through  it  in  preference  to  burrowing  along 
the  subcutaneous  cellular  tissue,  which  is  less  vascular  and  not  so  quickly 
converted  into  granulation  tissue.  Where  an  abscess  forms  beneath  a  dense 
fascia  the  conditions  are  different.  The  fascia  is  not  so  quickly  converted 
into  granulation  tissue  as  is  the  areolar  tissue  beneath,  and,  consequently, 
an  abscess  so  confined,  if  left  unopened,  will  extend  for  long  distances  and 
in  various  directions  beneath  the  fascia.  Ultimately,  however,  the  fascia 
undergoes  granulation,  or  sloughs  from  interference  with  its  blood  supply 
by  the  pressure  of  the  pus,  and  the  latter  escapes  into  the  subcutaneous 
tissue.  As  soon  as  this  takes  place  the  abscess  behaves  like  a  subcutaneous 
one  and  bursts  through  the  skin.  The  mode  in  which  the  abscess  burrows 
is  of  great  importance  from  the  point  of  view  of  treatment.  If  an  acute 
abscess  be  left  unopened  until  a  late  period  it  will  be  found  to  be  no  longer 
a  single  round  cavity,  but  one  containing  numerous  diverticula  corresponding 
to  the  directions  in  which  the  inflammation  has  extended  in  the  deeper 
tissues.  Unless  these  diverticula  are  thoroughly  opened  up,  the  mere 
evacuation  of  the  superficial  portion  of  the  abscess  will  often  fail  to  arrest 
the  progress  of  the  suppuration.  Perhaps  the  best  example  of  this  is  in 
the  breast,  where  the  abscess  is  rarely  found  to  consist  of  a  single  cavity, 
but  usually  possesses  many  diverticula,  corresponding  more  or  less  to  the 
ducts  and  lobules  of  the  breast.  If  an  abscess  of  this  kind  be  not  opened 
in  the  manner  to  be  presently  described,  the  pus  in  these  diverticula  will  be 
retained,  and  may  lead  to  fresh  openings,  the  ultimate  result  being  that 
the  whole  of  the  breast  becomes  riddled  with  sinuses. 


26  ACUTE    SUPPURATION. 

Treatment— Local. — When  pus  has  formed  it  should  be  evacuated  as 
soon  as  possible.  If  allowed  to  remain  unopened  the  abscess  will  go  on 
spreading,  and  thus  cause  a  great  deal  of  unnecessary  destruction  of 
tissue,  besides  in  some  cases  imperilling  the  patient's  life.  Hence,  when 
symptoms  of  acute  inflammation  have  lasted  for  several  days,  and  more 
especially  if  there  be  oedema  of  the  skin  over  the  part,  and  still  more  if 
rigors  have  occurred,  no  time  should  be  lost  in  making  an  incision  to 
find  the  pus. 

In  opening  an  acute  abscess  all  the  usual  antiseptic  precautions  should 
be  taken,  the  hair  being  shaved,  the  skin  purified,  and  so  forth,  in  the 
manner  described  for  the  treatment  of  wounds  (see  Chap.  VIII.).  At  first 
sight  this  may  seem  an  unnecessary  precaution,  because  these  abscesses, 
being  due  to  pyogenic  cocci,  already  contain  the  causes  of  suppuration. 
Practically,  however,  it  is  found  that  it  is  of  the  greatest  importance  to 
treat  the  abscess  strictly  antiseptically  from  the  first  As  a  matter  of  fact, 
when  an  abscess  is  opened  antiseptically  it  is  comparatively  easy  to  keep 
it  aseptic,  and  no  further  suppuration  occurs.  On  removing  the  first 
dressings  there  will  no  doubt  be  a  small  quantity  of  pus,  but  this  is  only 
the  residual  pus  which  was  present  in  the  abscess  at  the  time  of  the  open- 
ing, and  if  the  cavity  be  squeezed,  all  that  is  expelled  is  a  small  quantity 
of  clear  serum;  this  rapidly  diminishes,  and  in  a  few  days  the  abscess 
cavity  closes.  On  the  other  hand,  where  the  abscess  is  not  treated  anti- 
septically from  the  first,  suppuration  goes  on.  If,  for  example,  a  poultice 
be  applied,  it  will  be  found  that,  whenever  the  poultice  is  removed,  pus 
can  be  squeezed  out,  or  will  even  flow  out  spontaneously;  this  is  evidently 
due  to  fresh  infection  of  the  cavity,  for,  when  asepsis  is  maintained,  the 
organisms  which  originally  caused  the  abscess,  for  reasons  into  which  we 
need  not  enter  here,  die  out 

Opening  an  Abscess. — The  incision  into  an  acute  abscess  should  always, 
if  possible,  be  made  at  the  most  dependent  spot.  Unless  the  abscess  is 
situated  in  parts  such  as  the  face  or  the  neck,  where  the  size  of  the  scar 
may  be  a  matter  of  importance,  the  incision  through  the  skin  should  be 
sufficiently  free  to  allow  the  surgeon  to  introduce  his  finger,  with  the  view 
of  exploring  all  the  recesses  of  the  abscess  cavity  and  breaking  down  all 
the  septa  to  which  reference  has  just  been  made :  without  the  aid  of  touch 
this  cannot,  as  a  rule,  be  satisfactorily  done.  In  some  cases  where  the 
abscess  is  superficial,  and  the  size  of  the  scar  a  matter  of  great  importance, 
it  is  allowable  to  make  a  small  incision  just  large  enough  to  admit 
a  pair  of  dressing  forceps  and  subsequently  to  put  in  a  small  drainage 
tube.  Before  doing  this,  the  forceps  introduced  into  the  interior  of  the 
abscess  cavity  should  be  pushed  in  all  directions  and  the  blades  frequently 
expanded,  so  that  any  septa  present  may  be  broken  down  and  the  cavity 
thoroughly  opened.  In  certain  situations,  as,  for  instance,  in  the  anterior 
triangle  of  the  neck,  where  the  use  of  the  knife  in  the  deeper  tissues  would 
endanger  important  structures,  some  surgeons  prefer  to  use  the  plan  known 


CIRCUMSCRIBED   ACUTE   ABSCESS.  2/ 

as  Hilton's  method.  In  this  the  skin  only  is  incised,  the  knife  is  then 
laid  aside,  and,  with  a  pair  of  dressing  forceps,  or  Lister's  sinus  forceps, 
which  are  similar  to  dressing  forceps  but  with  much  finer  blades,  the 
deeper  tissues  are  carefully  bored  through  until  the  pus  is  reached. 
When  the  forceps  have  entered  the  cavity,  the  blades  are  expanded  until 
a  sufficient  opening  has  been  torn  in  the  tissues  to  enable  a  drainage 
tube  to  be  introduced.  As  before,  the  forceps  should  be  pushed  into  the 
cavity  in  all  directions  and  the  blades  frequently  expanded  so  as  to 
break  down  septa.  When  an  abscess  has  been  opened  in  this  way,  a 
probe  should  be  passed  along  the  side  of  the  forceps  before  their 
withdrawal,  so  as  to  act  as  a  guide  for  the  subsequent  introduction  of 
the  drainage  tube.  If  this  be  not  done,  the  opening  in  the  fascia  through 
which  the  forceps  entered  may  be  missed,  for  it  is  not  always  in  a  direct 
line  with  the  opening  in  the  skin.  The  simplest  way  of  introducing  the 
drainage  tube  is  to  thread  it  over  this  probe;  the  lower  end  of  the  tube  is 
grasped  with  the  sinus  forceps  and  gradually  pushed  into  the  abscess  cavity, 
and  then,  whilst  the  forceps  hold  the  tube  in  position,  the  probe  is 
withdrawn. 

Drainage. — Having  opened  the  cavity  of  the  abscess  freely,  and  having 
made  sure  that  no  diverticula  remain,  the  pus  should  be  gently  squeezed 
out,  violence  being  avoided  lest  the  granulation  tissue  should  be  injured. 
An  india-rubber  drainage  tube,  which  should  always  be  as  large  as  can 
be  conveniently  introduced — the  larger  the  better  in  the  first  instance — 
should  then  be  inserted  so  that  the  end  of  the  tube  projects  freely  into  the 
cavity ;  and  this  end  should  be  perforated  with  a  number  of  large  openings 
through  which  the  discharge  can  escape.  Where  the  abscess  cavity  is  very 
small,  and  does  not  extend  to  any  depth,  the  use  of  a  drainage  tube  may 
be  dispensed  with,  and  a  narrow  strip  of  gauze,  dipped  in  a  1-2000 
sublimate  solution,  laid  between  the  lips  of  the  incision  throughout  its  entire 
length.  This  suffices  to  keep  the  wound  open  sufficiently  for  drainage,  and 
may  be  discarded  in  a  few  days.  Where  the  abscess  is  very  large,  and 
especially  where  the  pus  has  burrowed  to  a  considerable  distance,  it  is 
often  necessary  to  provide  a  second,  or  counter  opening,  to  ensure  efficient 
drainage  for  the  pus ;  this  is  more  especially  necessary  where  the  original 
opening  has  not  been  made  at  the  most  dependent  point  of  the  abscess 
cavity.  To  make  a  counter  opening,  a  pair  of  sufficiently  long  dressing 
forceps  are  inserted  into  the  cavity  with  the  blades  closed,  passed  down  to 
the  most  dependent  point,  and  then  thrust  forcibly  outwards  so  that  they 
project  beneath  the  skin.  An  incision  is  then  made  through  the  skin  over 
them,  the  points  exposed,  the  blades  separated  and  made  to  grasp  a 
drainage  tube,  which  can  thus  be  pulled  through  the  aperture.  The  outer 
part  of  the  drainage  tube  should  be  cut  off  flush  with  the  skin,  and  stitched 
to  it  if  the  patient  is  under  an  anaesthetic.  This  is  the  simplest  plan  for 
securing  a  drainage  tube,  and  the  most  certain  to  keep  it  in  its  place.  If 
the  patient  has  not  had  an  anaesthetic,  it  suffices  to  pass  a  loop  of  thread 


28  ACUTE    SUPPURATION. 

through  the  outer  edge  of  the  tube,  so  as  to  have  a  means  of  pulling  out 
the  end  of  the  tube  should  it  slip  too  far  in ;  this  also  helps  to  prevent  the 
tube  from  slipping  in  because  of  the  friction  of  the  thread  upon  the  dressing. 
It  may  be  rendered  still  more  secure  by  passing  some  strands  of  dressing 
through  the  loop.  Another  simple  plan  is  to  transfix  the  end  of  the  drain- 
age tube  by  means  of  a  sterilized  safety  pin.  It  is  well  not  to  push  the 
tube  quite  down  to  the  bottom  of  the  cavity,  more  especially  if  stitched  to 
the  opening,  because  it  will  be  found  that  the  swelling  very  rapidly  goes 
down,  and  in  the  course  of  twenty-four  hours  a  tube  which  hardly  reached 
the  bottom  of  the  cavity  will  be  pushed  up,  sometimes  for  a  considerable 
distance,  pulling  the  skin  with  it.  So  long  as  the  tube  enters  the  abscess 
cavity,  or  any  recess  which  may  require  drainage,  it  is  sufficient. 

The  plan  of  washing  out  acute  abscesses  after  they  have  been  opened 
is  not  one  to  be  recommended.  It  can  do  no  good  whatever  in  the  way 
of  disinfecting  the  abscess,  whilst  it  is  very  apt  to  injure  the  granulation 
wall,  and  thus  produce  a  weak  spot  in  which  the  organisms,  which  would 
otherwise  die  out,  can  spread.  Similarly,  any  curetting  of  the  cavity  is  to 
be  strongly  deprecated.  This,  of  course,  only  applies  to  cases  of  acute 
abscess,  and  more  especially  to  those  where  efficient  drainage  has  been 
provided.  In  some  cases  where  the  anatomical  conditions  of  the  part  do 
not  allow  of  openings  being  made  at  the  lowest  point  of  the  abscess  cavity, 
as,  for  example,  in  certain  abdominal  abscesses,  it  is  necessary  to  syringe 
out  the  cavity  frequently,  with  the  object  of  removing  discharges  which 
otherwise  would  collect  and  decompose  at  the  lower  parts  of  the  wound. 
This  may  be  done  with  warm  1-2000  sublimate  solution,  or,  if  the  discharge 
be  very  foul,  with  sanitas  or  Condy's  fluid.  It  will  be  seen  when  we  come 
to  speak  of  the  treatment  of  chronic  abscess  that  curetting,  which  is  inad- 
missible in  cases  of  acute  abscess,  is  a  valuable  method  of  treatment  there. 

Dressings. — After  the  drainage  tube  has  been  inserted,  the  cyanide 
dressings  recommended  for  wounds  (see  Chap.  VIII.)  should  be  used. 

After-Treatment. — In  the  after-treatment  of  an  acute  abscess,  the 
dressings  should,  as  a  rule,  be  changed  on  the  following  day,  when  it  will 
be  found  that  the  swelling  has  considerably  diminished.  The  drainage 
tube  should  not  be  removed,  for  if  this  were  done  it  might  be  difficult  to 
get  it  back,  but  if  it  is  being  pushed  forward  the  retaining  stitches  should 
be  cut  and  the  projecting  portion  removed.  A  fresh  dressing  is  then  applied, 
the  orifice  of  the  wound  and  the  skin  around  being  previously  washed  with 
a  1-2000  sublimate  solution.  The  question  as  to  when  the  dressing  should 
again  be  changed  will  be  determined  by  the  amount  of  discharge.  With 
a  small  abscess  the  second  dressing  can  usually  be  left  on  for  three  or  four 
days.  Where,  however,  the  abscess  was  large,  and  where  there  is  a  con- 
siderable amount  of  serous  oozing,  it  is  well  to  change  the  dressing  on  the 
following  day.  In  most  cases  the  drainage  tube  can  be  left  out  on  the 
fourth  or  fifth  day,  but  the  point  which  determines  this  is  the  amount  of 
serous  discharge  present.  If  small,  there  need  be  no  hesitation  in  leaving 


DIFFUSE   CELLULITIS. 


29 


out  the  tube ;  but  if  the  discharge  is  still  considerable,  or  purulent,  the 
drainage  tube  should  be  continued.  At  any  rate,  a  tube  long  enough  to 
extend  from  the  orifice  of  the  skin  to  the  entrance  of  the  abscess  cavity 
should  be  retained,  as  otherwise  the  skin  wound  is  very  apt  to  close  with 
great  rapidity,  and  the  fluid  will  then  be  retained  in  the  interior,  and  lead 
to  the  reproduction  of  the  abscess. 

There  are  various  points  in  regard  to  acute  abscesses  in  various  situations 
which  will  be  referred  to  in  their  proper  place,  such  as  the  line  of  incision 
to  be  made,  and  the  various  difficulties  that  may  arise  in  opening  them. 
Suffice  it  here  to  recall  attention  to  the  essential  point  in  the  opening  of 
the  abscess,  namely,  the  thorough  breaking  down  of  all  septa  which  may 
shut  off  diverticula  which  would  not  otherwise  be  properly  evacuated. 

General  Treatment. — The  general  treatment  of  acute  abscess  is  the 
same  as  that  described  under  acute  inflammation  (see  p.  13).  As  soon 
as  convalescence  begins,  nourishing  diet,  fresh  air,  stimulants,  etc.,  are 
necessary. 

Diffuse  Cellulitis. — The  other  form  of  acute  suppuration  in  the 
cellular  tissue  to  which  we  have  already  referred,  is  diffuse  cellulitis, 
where  the  pus  is  not  contained  in  a  well-defined  abscess  cavity,  but  infil- 
trates the  tissues.  This  condition  is  due  to  the  presence  of  the  strepto- 
coccus pyogenes. 

Symptoms. — Not  only  is  there  infiltration  of  the  tissues  with  pus, 
but  death  of  some  portions  of  them  very  often  occurs,  and  these  dead 
portions  come  away  afterwards  as  sloughs.  The  local  inflammatory  con- 
dition spreads  with  great  rapidity,  the  skin  becomes  red,  brawny,  and,  as 
suppuration  occurs,  boggy,  but  it  is  very  difficult  to  make  out  any  distinct 
fluctuation,  at  any  rate  in  the  earlier  stages.  Later  on,  however,  it  is  not 
uncommon  to  find  that,  in  addition  to  the  infiltration  of  the  tissues  with 
pus,  there  is  somewhere  or  other  a  distinct  fluctuating  cavity.  The  infection 
tends  to  spread  along  the  lymphatic  vessels,  so  that  from  quite  an  early 
period  red  lines  are  seen  extending  up  the  arm,  for  these  abscesses  most 
commonly  occur  in  the  fore-arm  and  hand,  in  connection  with  scratches 
upon  the  hand  or  fingers.  As  the  infective  material  spreads  along  the 
lymphatic  vessels,  it  not  infrequently  bursts  through  their  walls  at  various 
parts,  leading  to  fresh  patches  of  diffuse  cellulitis,  and  thus  to  fresh  areas 
of  inflammation,  and  it  is  not  uncommon  for  the  condition  to  terminate  in 
pyaemia. 

The  general  symptoms  accompanying  this  local  condition  are  very  grave, 
presenting  the  characters  of  asthenic  inflammatory  fever,  already  referred 
to  (see  p.  3). 

Treatment — Local. — The  local  treatment  must  be  prompt  and  radical, 
and  should  consist  in  giving  free  and  early  exit  to  the  pus  and  sloughs. 
A  small  incision  in  this  case  would  do  no  good  whatever,  because  the  pus 
is  infiltrating  the  tissues,  and  could  not  escape  through  such  an  opening. 
It  is  absolutely  essential  that  the  incision  should  be  free,  and  should  extend 


3o  ACUTE    SUPPURATION. 

right  through  the  whole  of  the  inflamed  area.  If  one  incision  does  not 
suffice  to  lay  the  whole  of  it  open,  additional  ones  must  be  made  till 
the  entire  area  is  incised ;  in  any  case  it  should  expose  the  deep  fascia  of 
the  part,  and  must  go  even  deeper  if  necessary. 

After  the  incisions  have  been  made,  the  part  should  be  gently  squeezed, 
and  any  recesses  from  which  pus  wells  out  should  be  thoroughly  opened. 
When  the  surgeon  is  satisfied  that  all  the  recesses  have  been  opened, 
extremely  satisfactory  results  are  often  obtained  from  sponging  the  surface 
of  the  wound  with  undiluted  carbolic  acid,  with  the  view  of  destroying  the 
micro-organisms  if  possible.  When  the  wound  has  been  thus  treated,  it 
should  be  stuffed  with  strips  of  cyanide  gauze  wrung  out  of  a  1-2000 
sublimate  solution  and  sprinkled  with  iodoform,  and  then  the  ordinary  anti- 
septic dressing  applied  outside  (see  Chap.  VIIL). 

After-treatment. — Where,  in  spite  of  this  treatment,  the  process  does 
not  come  to  a  standstill,  resort  should  be  had  to  constant  irrigation  or  the 
employment  of  the  water  bath,  fresh  incisions  being  made  from  time  to 


FIG.  6. — CONSTANT  IRRIGATION  BY  MEANS  OF  A  STRAND  OF  WORSTED.     The  method 
of  arranging  the  mackintosh  so  as  to  drain  off  the  fluid  is  also  shown. 

time  over  any  area  showing  signs  of  extension  of  the  inflammation.  To 
carry  out  irrigation  the  first  point  to  remember  is  that  whatever  apparatus 
is  used  to  convey  the  fluid,  it  must  not  allow  the  latter  to  drop  on  to 
the  wound,  as  this  would  cause  intolerable  pain  in  a  very  short  time.  If 
a  tube  be  employed,  the  end  of  it  must  lie  upon  the  skin  at  the  highest 
point  of  the  wound.  Perhaps  the  simplest  and  best  plan  is  to  convey  the 
fluid  to  the  wound  by  means  of  capillary  action.  A  vessel  containing  the 
lotion  is  placed  at  a  higher  level  than  the  part,  and  a  strand  of  worsted, 


DIFFUSE   CELLULITIS.  3! 

one  end  of  which  hangs  in  the  lotion,  while  the  other  lies  on  the  upper  part 
of  the  wound,  is  employed  :  the  fluid  runs  along  these  threads  very  quickly, 
and  the  wound  is  thus  constantly  washed  with  it  (see  Fig.  6).  The  liquid 
used  for  irrigation  should  be  at  about  the  temperature  of  the  body,  and 
this  can  be  arranged  for  by  keeping  a  night-light  under  the  vessel  in  which 
it  is.  It  is  well  to  add  some  antiseptic,  but  it  is  important  to  avoid  those 


FIG.  7. — CONSTANT  IRRIGATION.  The  method  of  forming  a  drain  for  the  surplus  fluid 
by  means  of  the  mackintosh  is  also  shown.  The  nozzle  of  the  irrigator  should  always 
lie,  as  represented  above,  in  direct  contact  with  the  edge  of  the  sore. 

which  precipitate  albumen;  otherwise  the  surface  of  the  sore  will  become 
coated  with  a  layer  of  coagulated  albumen,  and  the  pus  and  organisms  will 
accumulate  beneath  it  instead  of  being  washed  away.  Perhaps  the  best 
for  the  purpose  are  permanganate  of  potash  or  sanitas  (a  teaspoonful  of 
sanitas  to  the  tumbler  of  water,  or  two  to  four  grains  of  permanganate 
of  potash  to  the  ounce).  In  irrigating,  care  must  of  course  be  taken  not 
to  wet  the  bed,  and  a  mackintosh  should  be  so  arranged  that  the  fluid  is 
conducted  into  a  basin  at  the  bed-side  (see  Fig.  7).  If  possible,  it  is  well 
to  have  the  limb  suspended  over  an  empty  vessel,  but  in  any  case  a  piece 
of  mackintosh  should  be  arranged  beneath  it.  Of  course,  as  in  all  other 
inflammations,  the  limb  should  be  placed  at  a  higher  level  than  the  rest 


ACUTE    SUPPURATION. 


of  the  body.  In  the  case  of  the  arm,  it  may  be  made  to  rest  upon  a  pillow, 
covered  with  mackintosh,  the  upper  end  of  which  is  carefully  tucked  around 
the  shoulders  of  the  patient,  and  the  sides  so  folded  that  a  drain  is  formed 
which  will  prevent  the  bed  from  becoming  soaked.  In  Fig.  8  is  shown  a 
simple  method  of  extemporizing  an  irrigator  where  none  of  the  ordinary 
forms  are  available.  Another  precaution  which  is  necessary  in  employing 
irrigation,  is  to  prevent  the  neighbourhood  of  the  affected  part  becoming 
soddened  with  water,  and  for  this  purpose  the  skin  all  around  may  be 
smeared  with  grease  or  oil.  Irrigation  should  be  continued  until  the 
acuteness  of  the  inflammation  has  passed  off,  and  then  it  should  be 
changed  for  some  simple  dressing;  otherwise  the  granulations  are  likely  to 
become  cedematous,  and  a  weak  or  oedematous  ulcer  is  formed  which  will 
not  heal  properly.  Perhaps  the  best  dressing  at  this 
period  is  weak  boracic  ointment  (about  a  quarter  the 
strength  of  the  pharmacopceial  ointment)  spread  on 
butter  cloth,  with  a  layer  of  boracic  lint  applied  outside, 
or  else  the  protective  and  boracic  lint  dressing  which 
will  be  described  under  the  treatment  of  ulcers  (see  p.  47). 
Another  very  good  method  of  treatment,  although 
hardly  so  satisfactory  as  irrigation,  is  the  water  bath.  In 
irrigation  the  main  principle  is  that,  the  secretions  being 
washed  away  as  rapidly  as  they  form,  no  nidus  remains 
in  which  micro-organisms  can  grow.  In  the  case  of  the 
water  bath,  the  discharges  are  not  washed  away  so  rapidly 
as  by  irrigation,  but  they  are  so  diluted  that  the  organ- 
isms do  not  find  satisfactory  pabulum  in  them  ;  at  the 
same  time  the  bath  supplies  warmth  and  moisture  in  a 
very  efficient  manner.  In  either  case,  if  an  antiseptic, 
such  as  sanitas,  permanganate  of  potash,  boracic  acid,  or 
weak  iodine,  be  added  to  the  fluid,  there  is  also  a  cer- 
tain amount  of  inhibition  of  the  growth  of  the  organisms. 
In  employing  the  water  bath,  the  limb  is  suspended, 
by  means  of  a  large  gauze  or  muslin  sling,  in  a  covered 


FIG.  8.— IRRIGATOR.    bath   (see    Fig.    o),   filled   with   water  at  a  temperature   of 

To  show  how  an  irrig-  e  .    .  . 

ator  can  be  improvised    about  ioo    r.  and  containing  one  of  the  above  antiseptics 
in   solution.      The  bath  should  be  furnished   with   a 


tap 


from  a  wine  bottle  :  the 
bottom  of  the  bottle 
should  be  cut  off  and  .. 

the  neck  plugged  with    at  the  lower  part,  and  a  gentle  stream  of  warm  water  (at 

a  cork   which    is    tra-  o     T^  \       u        i  J     fl  *u  i-     •*.     L  r  i 

versed  by  a  piece  of    no     F.)   should  flow  through  it  by  means   of  a   syphon 
apparatus,  from  a  reservoir  above  the  level  of  the  limb ; 


glass    tubing. 
Thierscft.) 


(After 


every  ten  or  twelve  hours  the  bath  should  be  emptied  and 
flushed  out,  as  otherwise  the  fluid  is  very  apt  to  decompose.  The  skin 
around  the  wound  should  be  carefully  oiled.  The  water  bath  should  only 
be  used  during  the  day,  and  during  the  night  boracic  lint,  wetted  with 
boracic  lotion  and  covered  with  mackintosh,  should  be  applied  in  the  same 
way  as  a  water  dressing.  The  bath  requires  constant  attention  in  order  to 


DIFFUSE  CELLULITIS. 


33 


keep  the  water  warm,  to  prevent  it  from  overflowing,  and  to  empty  it  from 
time  to  time,  etc.,  and,  therefore,  the  patient  would  be  disturbed  and  unable 
to  get  proper  sleep  if  the  bath  were  employed  during  the  night.  Further, 
the  limb  must,  in  any  case,  be  removed  from  the  bath  at  the  end  of  ten 


FIG.  9. — WATER  BATH  FOR  LEG.  The  sloping  floor  of  the  bath  is  meant  for  the  leg 
to  rest  upon  :  it  is  better,  however,  to  have  holes  bored  through  the  sides  of  the  bath 
near  the  top,  to  which  can  be  fastened  slings  of  muslin  in  which  the  limb  rests.  The 
bath,  when  in  use,  is  covered  over  with  a  thick  blanket  to  maintain  its  temperature. 

or  twelve  hours,  so  as  to  have  the  latter  thoroughly  scrubbed  out ;  moreover, 
prolonged  soaking  in  warm  water  does  not  improve  the  resisting  power  of 
the  tissues.  Where  the  feet  or  the  forearm  are  affected,  a  water  bath 
works  very  well,  but,  in  the  latter  case,  the  patient  must  be  propped  up 
more  or  less  in  a  sitting  posture. 


FIG.  10. — WATER  BATH  FOR  HAND  AND  FOREARM.      The  apparatus  works  more 
satisfactorily  if  it  be  furnished  with  a  tap,  as  in  Fig.  9. 

Where  the  upper  part  of  the  limbs  or  the  trunk  are  affected,  the  patient 
must  lie  in  an  ordinary  bath  arranged  for  the  purpose.  In  this  case,  if 
the  trunk  be  not  entirely  submerged,  care  must  be  taken,  by  means  of  a 
blanket  fastened  round  the  neck  and  covering  in  the  bath,  to  prevent  any 
risk  of  the  patient  taking  cold. 

Failing  the  use  of  irrigation  or  the  warm  bath,  the  next  best  treatment 
is  by  moist  dressings,  consisting  of  boracic  lint  wrung  out  of  warm  boracic 
lotion,  or  weak  sublimate  solution,  and  applied  over  the  whole  surface  of 
the  wound,  and  then  covered  with  a  piece  of  mackintosh  larger  than  the 
lint,  and  extending  beyond  it  in  all  directions.  This  requires  to  be  changed 

c 


34 


ACUTE    SUPPURATION. 


frequently,  as  often  as  three  or  four  times  a  day,  and  the  wound  and  the 
skin  around  should  be  washed  with  a  1-2000  perchloride  solution  when 
the  dressing  is  changed.  When  the  acuteness  of  the  symptoms  has  passed 
off,  dry  dressings,  that  is  to  say,  boracic  lint  applied  wet  and  allowed  to 
dry,  or  else  weak  boracic  ointment,  are  the  best  treatment.  When  healing 
has  commenced  the  ointment  is  undoubtedly  better,  because  the  dry  boracic 
lint  is  very  apt  to  stick  to  the  sore  and,  when  the  dressing  is  changed, 
to  tear  off  the  newly-formed  epidermis.  Where  ointments  are  used  they 
must  be  spread  on  thin  muslin  and  changed  once  or  twice  a  day. 

Certain  other  points  must  be  attended  to  in  the  local  treatment  of 
diffuse  cellulitis.  It  is  of  primary  importance  that  the  part  should  be 
placed  absolutely  at  rest,  if  necessary  on  a  splint,  and  the  position  of  the 
limb  should  be  so  arranged  that,  should  stiffness  take  place,  as  it  is  very 
apt  to  do,  the  limb  will  be  in  the  position  most  convenient  for  the  patient. 
For  example,  in  the  case  of  the  hand  the  fingers  should  not  be  stretched 
out,  because  if  they  become  stiff  in  that  position  they  are  useless ;  they 
should  be  about  half-bent  over  a  pad,  and  the  thumb  especially  should  be 
kept  apart  from  the  fingers,  and  allowed  to  drop.  If  the  thumb  be  kept 
at  the  same  level  as  the  fingers,  and  stiffness  result,  the  power  of  opposition 
is  more  or  less  lost ;  whereas,  if  it  be  allowed  to  drop  below  the  level  of 
the  fingers,  then,  even  with  comparatively  limited  movement,  fairly  small 
objects  can  be  picked  up  between  the  fingers  and  thumb.  To  lay  the 
whole  hand  flat  on  a  splint,  with  the  thumb  at  the  side  of  the  fingers,  is  a 
mistake  so  commonly  made  that  too  much  attention  cannot  be  called  to 
it.  The  elbow  or  the  foot  should  be  put  up  at  a  right  angle,  the  knee 
very  slightly  flexed,  etc. 

Passive  Motion. — When  the  acuteness  of  the  inflammation  has  passed 
off,  steps  must  be  taken  to  prevent  any  subsequent  stiffness  of  the  part, 
for  in  diffuse  cellulitis,  spreading  as  it  does  in  the  planes  of  the  cellular 
tissue,  and  accompanied,  as  it  very  often  is,  by  sloughing,  the  parts  are 
very  apt  to  become  adherent  to  one  another.  Thus,  in  the  forearm,  what 
with  the  inflammation  causing  adhesion  of  the  muscles  to  one  another,  and 
what  with  gangrene  of  portions  of  the  muscle  or  even  of  the  tendons,  the 
hand  is  likely  to  be  permanently  useless.  Hence,  directly  acute  symptoms 
have  passed  off,  the  splint  must  be  given  up,  and,  to  a  certain  extent, 
rapidity  of  healing  must  be  sacrificed  to  the  attempt  to  promote  move- 
ment. The  patient  should  be  encouraged  to  move  the  fingers,  the  wrist, 
and  the  elbow  joint,  two  or  three  times  daily,  and  in  addition  to  this, 
passive  movement  of  these  parts  ought  also  to  be  carried  out  at  least  once 
or  twice  a  day. 

Massage. — As  soon  as  possible  after  the  wound  has  healed,  massage 
and  passive  and  active  movements  should  be  steadily  persevered  in,  with 
the  view  of  getting  rid  of  the  effused  material,  and  of  freeing  the  adhesions 
between  the  muscles.  This  massage  is  carried  out  on  the  principles  already 
alluded  to  (see  p.  22),  and  it  should  be  accompanied  by  passive  motion, 


DIFFUSE  CELLULITIS. 


35 


with  the  view  of  breaking  down  adhesions  in  the  joints  and  between 
tendons.  In  bad  cases,  this  passive  movement  may  be  undertaken  two  or 
three  times  a  week  under  an  anaesthetic,  but  care  must  be  taken  not  to  do 
too  much  at  a  time,  as  otherwise  fresh  effusion  is  caused,  and  the  object  of 
the  procedure  is  defeated. 

General  Treatment. — The  general  treatment  of  diffuse  cellulitis  must 
be  very  carefully  attended  to.  As  has  already  been  said,  it  is  a  very 
grave  disease,  and  the  patient  is  very  apt  to  pass  into  the  typhoid  state, 
hence  free  stimulation  is  above  all  things  necessary,  and  perhaps  the  best 
stimulant  to  employ  is  brandy.  Where  the  patient,  however,  is  very  much 
exhausted,  champagne  will,  at  any  rate  temporarily,  have  a  better  effect.  If 
brandy  be  given,  at  least  six  ounces  should  be  administered  in  the  twenty- 
four  hours,  and  in  some  cases  where  the  pulse  is  very  weak,  a  considerably 
larger  amount  may  be  necessary.  Strychnine  injected  hypodermically  is  also 
of  great  value.  Every  attempt  should  be  made  to  promote  the  patient's 
nourishment,  and  this  must  be  carried  out  on  the  lines  already  laid  down 
for  the  treatment  of  acute  inflammation  (see  p.  13). 

Diffuse  cellulitis  in  certain  situations,  e.g.  scalp,  neck,  etc.,  will  be  treated 
of  in  their  appropriate  places.  The  essential  facts  to  remember  with  regard 
to  diffuse  cellulitis  in  general  are  the  rapidity  of  the  disease,  the  necessity 
for  very  early  surgical  intervention,  and  the  desirability  of  extremely  thorough 
measures.  As  a  matter  of  fact,  one  is  much  more  likely  to  do  too  little 
than  too  much  in  the  way  of  free  incisions  into  the  part. 


CHAPTER   III. 

ULCERATION. 

DEFINITION. — An  ulcer  has  been  roughly  defined  as  any  breach  of 
the  skin  or  mucous  membrane  which  does  not  tend  to  heal.  This  defini- 
tion includes,  however,  not  merely  ulcers  proper,  the  result  of  inflammatory 
processes,  but  also  ulcerating  tumours,  with  which  we  shall  not  deal  in  the 
present  chapter.  True  ulceration  is  an  inflammatory  process,  and  a  more 
accurate  definition  is,  that  an  ulcer  is  a  progressive  loss  of  substance  in  skin 
or  mucous  membrane  which  has  previously  been  the  seat  of  inflammatory 
changes  that  have  gone  on  to  granulation.  This  continued  loss  of  sub- 
stance is  not  due  to  death  of  visible  portions  of  tissue  (in  which  case  there 
would  be  gangrene),  but  to  degeneration  of  cells,  or  death  of  microscopic 
portions  of  the  tissue — what  is  known  as  molecular  death. 

CLASSIFICATION. — There  are  two  great  classes  of  ulcers  proper, 
namely,  (i)  those  which  are  not  due  to  any  specific  virus,  but  are  caused 
by  various  local  troubles,  such  as  imperfections  in  the  blood  supply  or 
innervation  of  the  part.  This  class  may  be  spoken  of  as  the  chronic 
non-infective  ulcer.  (2)  Those  in  which  a  specific  virus  is  at  the  root  of 
the  ulcerative  process ;  this  includes  a  large  group  of  ulcers,  by  far  the 
greater  number  being  the  result  of  syphilitic  or  tubercular  disease.  These 
are  the  chronic  infective  ulcers.  In  these  latter  there  is,  preceding  the 
ulcerative  process,  a  formation  of  new  tissue  which  has  a  special  tendency 
to  undergo  degeneration ;  for  example,  syphilitic  nodules  undergo  gum- 
matous  degeneration,  and  tubercles  undergo  caseation,  the  result  of  these 
degenerative  changes  being  ulceration.  These  chronic  infective  ulcers  will 
be  discussed  more  in  detail  in  speaking  of  syphilis,  tubercle,  etc. ;  here  we 
shall  only  deal  with  the  chronic  non-infective  ulcers  which  result  directly 
from  inflammation. 

CAUSES. — Before  proceeding  to  discuss  the  treatment  of  ulcers,  it  is 
necessary  to  consider  the  causes  which  lead  to  the  ulcerative  process,  and 
the  various  types  of  ulcers  they  produce.  The  causes  of  ulceration  are 
mainly  local,  and  among  the  chief  is  anything  which  tends  to  produce 
defective  circulation  of  blood  in  the  part.  For  example,  if  an  inflamed  limb 
hangs  down,  the  return  of  the  venous  blood  is  impeded ;  consequently 
less  arterial  blood  flows  to  the  part,  and  its  nutrition  is  therefore 


CAUSES  OF  ULCERS. 


37 


interfered  with  :  this  is  the  explanation  of  the  fact,  that  the  great  majority 
of  ulcers  affect  the  lower  extremities.  A  granulating  wound  on  the  leg 
is  very  apt  to  become  the  subject  of  an  ulcerative  process  if  the  patient 
continue  to  walk  on  the  leg,  or  to  stand  about  much,  or  even  to  hang 
it  down.  Perhaps  one  of  the  most  frequent  causes  of  ulceration  is  the 
presence  of  varicose  veins,  more  especially  where  the  veins  affected  are  the 
small  branches  in  the  skin.  Under  these  circumstances,  there  is  a  very 
marked  obstacle  to  the  venous  return ;  consequently  there  is  great 
stagnation  of  blood  and  the  nutrition  of  the  part  is  impaired.  Again,  apart 
from  any  venous  obstruction,  ulceration  may  also  result  from  imperfect 
blood  supply,  as  is  seen  in  the  cases  where  there  is  atheroma  of  the 
arteries,  and  if,  to  the  presence  of  this  disease,  the  dependent  position 
be  superadded,  the  ulcerative  process  may  go  on  rapidly.  This  imperfect 
blood  supply  may  also  be  brought  about  by  the  pressure  of  the  inflam- 
matory exudation  in  the  tissues  around  the  ulcer  interfering  mechanically 
with  the  circulation  of  blood  in  the  part.  This  is  more  especially  the 
case  where  the  sore  is  situated  over  loose  connective  tissue,  the  meshes 
of  which  become  distended  with  lymph  and  which  is,  moreover,  sparsely 
supplied  with  blood-vessels. 

In  addition  to  these  causes  depending  upon  defective  circulation  of 
blood,  ulceration  is  greatly  favoured  by  a  feeble  condition  of  the  tissues 
such  as  occurs  in  old  age.  A  wound  on  the  leg  in  a  young  subject,  even 
although  he  has  varicose  veins  and  still  continues  to  walk  about,  is  not 
nearly  so  likely  to  lead  to  an  ulcer  as  is  a  similar  injury  in  an  old  person ; 
this  is,  to  a  great  extent,  due  to  the  greater  vitality  and  recuperative  power 
of  the  tissues  in  the  young.  At  the  same  time,  in  old  persons  there  is 
generally  a  diminution  in  the  arterial  supply,  and  thus  there  is  a  combina- 
tion of  at  least  two  of  the  causes  of  ulceration.  A  similar  result  is  brought 
about  by  anything  which  temporarily  enfeebles  the  vitality  of  the  part, 
such  as  severe  and  long-continued  exposure  to  cold.  This,  short  of  pro- 
ducing gangrene,  may  lead  to  rapid  ulceration. 

Another  local  cause  which  leads  to  ulceration  is  movement.  Where 
a  sore  is  situated  over  a  muscle,  or  over  a  fascia  which  is  in  frequent 
movement,  more  especially  if  adherent  to  either,  ulceration  is  more  likely  to 
occur  than  in  one  situated  elsewhere. 

Another  very  frequent  cause  of  ulceration  is  difficulty  in  the  contraction 
of  the  sore.  When  a  wound  heals  by  granulation,  an  important  element  of 
the  healing  process  consists  in  the  diminution  in  the  size  of  the  sore,  from 
the  contraction  of  the  newly  formed  fibrous  tissue ;  when  this  contraction 
cannot  occur,  a  time  will  come,  especially  if  the  sore  be  large,  when  healing 
will  cease  and  ulceration  will  take  place.  The  constant  unsuccessful  efforts 
of  the  new  fibrous  tissue  to  contract,  seem  to  irritate  the  part  and  arrest  the 
healing.  This  inability  to  contract  may  result  from  the  great  size  of  the 
sore,  or  from  its  adhesion  to  tissues,  such  as  a  bone  or  a  dense  fascia, 
which  do  not  permit  of  contraction,  or  from  induration  of  the  margin  of 


38  ULCERATIOX. 

the  sore,  as  in  a  callous  ulcer.  Not  only  does  the  difficulty  in  contraction 
lead  per  se  to  ulceration,  but  the  new  tissue,  in  contracting,  compresses 
the  blood-vessels  going  to  the  part,  and  so  interferes  with  the  proper  blood 
supply. 

Again,  irritation  of  a  sore  may  lead  to  ulceration  instead  of  healing, 
either  mechanically,  as  by  pressure,  by  friction  of  the  dressings,  etc.,  or 
chemically,  as  by  irritation  due  either  to  the  lotion  used  in  the  treatment, 
(for  example,  carbolic  acid),  or  to  decomposing  secretions.  Where  the 
discharge  from  a  sore  decomposes,  irritating  materials  are  formed  which 
may  lead  to  extensive  ulceration,  especially  if  they  do  not  readily  escape. 
This  is  most  often  the  case  where  the  discharge  dries  up  and  forms  crusts : 
under  these  crusts  this  decomposing,  irritating  secretion  accumulates,  and 
ulceration  instead  of  healing  occurs.  Hence  it  is  of  great  importance  in 
treating  an  ulcer,  or  a  septic  granulating  wound,  not  to  permit  the 
formation  of  crusts  or  scabs. 

Ulceration  may  also  be  set  up  by  accidental  contamination  of  the  wound. 
A  wound  which  is  healing  will  begin  to  ulcerate  if  virulent  pyogenic 
organisms  attack  it ;  they  lead  to  the  formation  of  an  inflammatory  ulcer. 
Among  other  specific  infections  of  sores  may  be  mentioned  diphtheria 
and  phagedena,  the  latter  of  which  will  be  dealt  with  more  fully  in  con- 
nection with  gangrene. 

Ulcers  also  occur  in  parts  where  the  nervous  supply  is  imperfect;  for 
example,  after  paralysis  or  neuritis.  To  some  extent  this  may  be  due  to 
the  fact  that  the  patient's  cutaneous  sensibility  is  diminished,  and  thus  he 
tolerates  greater  and  more  continued  pressure  on  one  particular  spot  than 
the  tissue  can  bear :  the  loss  of  the  regulating  trophic  influence  of  the 
nervous  system  is  also,  without  doubt,  of  great  importance. 

Lastly,  ulcers  may  occur  in  connection  with  certain  constitutional 
conditions,  such  as  diabetes,  scurvy,  etc.  Diabetes  leads  to  ulceration, 
partly  from  the  diminished  blood  supply  due  to  the  endarteritis  which  so 
often  accompanies  it,  and  partly  from  the  increased  susceptibility  of  the 
tissues  to  septic  infection.  Scurvy  leads  to  extravasation  of  blood  into 
the  tissues,  interfering  with  their  vitality,  and  often  ending  in  sloughing 
of  the  skin. 

Summary  of  causes.  In  regard  to  treatment,  the  various  causes  which 
lead  to  ulceration  may  be  most  conveniently  divided  into  six  great  groups, 
(i)  The  nature  of  the  tissue.  Where  the  tissue  is  loose  and  not  very 
vascular,  its  vitality  is  not  great,  and  the  blood  supply  is  more  readily 
interfered  with  by  the  exudation.  (2)  Anomalies  in  the  circulation,  either 
local  or  general;  such  as  local  anaemia  or  venous  hyperaemia,  venous 
obstruction  and  pressure  of  exudation  upon  the  vessels,  etc.  Under  this 
heading  may  also  be  included  ulcers  in  old  people,  where  the  tissues  are 
less  vascular  and  the  vessels  diseased.  (3)  Local  disturbances  of  innerva- 
tion,  due  to  various  diseases  of  the  central  or  peripheral  nervous  system. 
(4)  Local  irritation,  long  continued  or  frequently  repeated,  mechanical  or 


VARIETIES  OF  ULCERS. 


39 


chemical.  The  chemical  causes  are  decomposing  secretions  or  improperly 
selected  lotions.  (5)  Local  conditions,  such  as  the  seat  of  the  sore,  its 
size,  its  form,  its  relation  to  surrounding  parts ;  the  tension  of  the  neigh- 
bouring skin ;  fixation  of  the  sore  to  the  parts  beneath,  to  the  fascia  or 
bone;  marked  difference  of  level  between  the  margins  of  the  sore  and 
its  surface,  etc.  (6)  Local  disturbances,  such  as  acute  inflammation,  phage- 
denic  infection,  etc.,  or  general  conditions,  such  as  diabetes,  scurvy,  or 
other  similar  affections. 

VARIETIES. — Various  forms  of  ulcers  are  described,  of  which  the 
following  may  shortly  be  mentioned :  (i)  Simple  Ulcer. — This  may  be 
described  as  a  granulating  wound  which  is  not  healing.  These  sores  are 
kept  from  healing  by  various  local  causes  such  as  pressure  or  friction  from 
the  dressings,  muscular  movements,  scratching,  interference  with  the  vascular 
supply,  chemical  agencies  and  so  forth.  In  the  early  stage,  the  simple 
ulcer  forms  flat  sores  covered  with  granulations  of  a  yellow  or  brownish- 
red  colour,  on  a  level  with  the  surrounding  skin  or  only  slightly  depressed 
beneath  it.  The  margins  are  sharply  cut,  the  surrounding  parts  are  slightly 
cedematous.  These  ulcers  extend  fairly  rapidly  where  no  proper  care  is 
taken.  In  certain  cases,  these  and  other  ulcers  may  become  the  seat  of 
acute  inflammation,  and  then  we  have  the  second  form,  namely,  the  inflamed 
ulcer. 

(2)  Inflamed  Ulcer. — This  is  an  ulcer  which   has  become  the  seat  of 
acute  inflammation,  as  the  result  of  some  mechanical  or  chemical  irritation, 
of  bad  methods  of  treatment,  or,  most  usually,  of  septic  infection.     In  these 
cases  the  surface  of  the  ulcer  becomes  intensely  red  and  angry-looking,  it 
bleeds  readily,  secretes  a  large  quantity  of  pus,  extends  with  great  rapidity 
and  is  not  infrequently  covered  with  small  shreds  of  actually  gangrenous 
tissue;    the   skin   around   is    bright   red   and   cedematous,    the   borders   are 
irregular   and   eaten   away,   and   it    is   not   uncommon  for   fresh   ulcers   to 
develop  rapidly  around  the  margin  of  the  original  sore.     These  fresh  ulcers 
are   at   first   separated  from  one   another,   and  from   the   original   sore,  by 
bridges    of  skin,    which   are   sometimes    quite    narrow,    intensely    inflamed, 
swollen,  and  very  apt  to  slough. 

(3)  Irritable   Ulcer. — This    form    of  ulcer    is    sometimes    met   with    in 
neurotic  women  as  a  small   sore   with   a  somewhat  elevated   surface,   and 
intensely   tender   to   the   slightest   touch.     It   commonly  occurs   about   the 
external  malleolus,  and  is  usually  associated  with  menstrual  disorders. 

(4)  Weak  Ulcer. — A  simple  ulcer  is  very  apt  to  become  a  weak  one 
as  the  result  of  defective  blood  supply,  either  from  too  small  a  quantity  of 
blood   reaching  the    part,  or   from   deficient    quality   of  the   blood,   as   for 
example  where  ulcerations  occur  during  the  progress  of  some  constitutional 
disease.     There  are  various  kinds  of  weak  ulcers,  depending  upon  the  cause 
producing  them.     In  one  form,  the  granulations  become  smooth  and  some- 
what yellowish,  the  secretions  thin,  small  in  amount  and  very  apt  to  form 
a  scab,  and  the  edges  pale  and   flat.     In  a  second  form,   the  granulations 


40  ULCERATION. 

become  cedematous,  and  this  usually  happens  in  connection  with  some 
general  cause  of  oedema,  or  some  local  interference  with  the  circulation, 
more  especially  the  venous  return.  In  a  third  form,  the  granulations  show 
excessive  growth;  this  generally  occurs  when  the  ulceration  is  due,  either 
to  the  inability  of  the  sore  to  contract,  or  to  irritation  from  the  materials 
used  for  dressing.  In  such  cases  the  granulations  become  prominent, 
vascular,  soft,  and  bleed  readily,  and  the  condition  is  one  popularly  spoken 
of  as  "  proud  flesh." 

(5)  Diphtheritic  or  Phagedenic  Ulcer. — Any  ulcer  may  be  attacked  by 
some  specific  virus,  such  as  the  diphtheritic,   or  with  that  which  produces 
phagedena.     In  the  latter  case  its  surface  becomes  covered  with  a  greyish, 
pulpy  material,  which  rapidly  infiltrates  the  surrounding  skin  and  cellular 
tissue,  extends  both  superficially  and  deeply,  leads  to  extensive  and  very 
rapid   destruction,   constitutional   infection,    and   not   uncommonly   ends   in 
the  death  of  the  patient. 

(6)  Vaxicose  Ulcer. — This  is  a  type  of  ulcer  which  originates  in  con- 
nection with  varicose  veins,  more  especially  where  the  smaller  veins  of  the 
skin  are  affected.     This  condition  of  varicosity  of  the  smaller  veins  leads 
to  imperfect  nutrition  of  the  skin,  and  either  to  the  occurrence  of  a  local 
dermatitis  ("varicose  eczema")  or  to  a  periphlebitis  and  the  formation  of 
a  small  abscess  around  the  vein  :    the  abscess  bursts,  and  gives  rise  to  an 
ulcer.     In  the  eczematous  variety,  the  patient  usually  scratches  the  irritable 
part  and  produces  a  wound,  which  becomes  inflamed  and  rapidly  develops 
into  an   ulcer.     However   produced,    these   varicose   ulcers   are  usually,  at 
first,  small  and  superficial,  with   oedema  around,  and  with  soft,  prominent, 
and  somewhat   cedematous  granulations.     If  the  patient  continues  to  walk 
about,  the  condition  gradually  passes  into  that  of 

(7)  Callous  Ulcer. — As  a  result  of  the  continued  interference  with  the 
venous  return,  local  oedema  takes  place;   there  is  exudation  of  coagulable 
lymph  in  the  interstices  of  the  cellular  tissue,  and  cells  accumulate  there, 
the  result  being  that  the  arterioles  are  much  pressed  upon,  and  the  nutri- 
tion of  the  sore  interfered  with.     The  exuded  material  coagulates,  and  to 
a  considerable   extent   becomes   organized,   and   hence  the   skin   and   sub- 
cutaneous tissues  around  the  ulcer  become  very  much  thickened,  so  that 
the  surface  of  the  ulcer  comes  to  lie  at  a  considerably  lower  level  than  its 
edge  ;  this  is  not  really  due  to  extension  of  the  ulcer  in  depth,  but  rather 
to   the   elevation    of  the   surrounding   part  owing  to  the  great  thickening. 
Thus,  the  characteristics  of  a  callous  ulcer  are — a  sore  at  a  deeper  level 
than  the  surrounding  skin,   a  hard  indurated  condition  of  its  base  and  of 
the   surrounding   part,   and   a   surface   of  a   pale   yellow  colour,   devoid  of 
granulation,  and  secreting  a  small  quantity  of  thin  fluid. 

(8)  Haemorrhagic  Ulcer. — This  is   a   form    of  ulcer  which  occurs  more 
especially  in  patients  suffering  from  scurvy ;  the  surface  of  the  sore  is  red, 
swollen,  and   bleeds   readily,  and  the  blood  sometimes   coagulates  on  the 
surface,  forming  a  firm  clot  which  was  formerly  spoken  of  as  "  bullock's  liver." 


VARIETIES  OF  ULCERS.  41 

(9)  Pressure  Ulcer. — This  form  of  ulcer  occurs  in  the  sole  of  the  foot, 
and  is   the   result   of  long-continued    but   not   necessarily  severe   pressure. 
In    the    first    place,    the    pressure    leads    to    thickening  »of    the    epidermis 
and   the   formation    of   a    callosity,    and    underneath    this    callosity   inflam- 
mation   and   suppuration    occur.      When    the    thickened    epidermis    is    re- 
moved,   a  deep  sore  with  great  hypertrophy  of  the  skin  around  the  edge 
is  exposed. 

(10)  The  Paralytic  Ulcer  is  one  that  occurs  in  connection  with  deficient 
innervation.     In  paralysed  limbs  it  is  not  uncommon  to  meet  with  atonic 
ulcers  which  are  painless,  quite  superficial  and  often  multiple.     They  have 
as  a  rule  imperfect  granulations  upon  the  surface,  and  they  most  commonly 
occur  about  the  phalanges  of  the  fingers  and  toes.     They  are  also,  however, 
found  on  the  sole  of  the   foot,   and   in   this    situation    they    are    generally 
ascribed  to  pressure,  and    assume   more   the   appearances   characteristic  of 
pressure  ulcers. 

In  connection  with  these  ulcers  due  to  pressure  upon  a  paralysed 
part,  the  so-called  perforating  ulcer  of  the  foot  deserves  special  notice. 
It  occurs  on  parts  exposed  to  marked  pressure,  and  is  chiefly  met  with 
beneath  the  heads  of  the  metatarsal  bones,  more  especially  that  of  the 
great  toe.  It  is  generally  seen  in  men  over  40  who  have  much  standing 
or  walking,  and  it  is  not  necessarily  connected  directly  with  any  actual 
paralytic  condition  of  the  limb,  but  is  supposed  to  result  from  a  con- 
dition of  peripheral  neuritis.  The  affection  commences  as  a  callosity, 
followed  by  inflammation  of  the  skin  underneath,  and  a  sore  forms, 
resembling  at  first  in  all  respects  an  ordinary  pressure  ulcer.  The  ulcer 
extends  in  depth,  becomes  more  or  less  funnel-shaped,  and  rapidly  pene- 
trates as  far  as  the  bone.  The  latter  may  then  become  the  seat  of  a 
rarefying  osteitis,  and  may  be  entirely  destroyed  opposite  the  ulcer,  which 
continues  to  increase  in  depth  until  ultimately  the  dorsum  of  the  foot  is 
reached  and  a  complete  perforation  is  established.  When  the  ball  of  the 
toe  is  the  seat  of  the  affection,  the  metatarso-phalangeal  joint  is  often 
opened  and  destroyed.  The  base  of  the  ulcer  is  generally  covered  with 
reddish  warty  granulations,  the  skin  is  very  foul,  and  the  cavity  of  the 
ulcer  is  filled  up  by  a  dense  mass  of  epidermis,  which  undergoes  foul 
decomposition.  In  some  cases  the  epidermis  spreads  down  the  sides  of 
the  ulcer,  and  in  many  there  is  marked  proliferation  of  it  around  the  mar- 
gins of  the  sore. 

(n)  In  certain  constitutional  states,  such  as  diabetes,  ulcers  may  form. 
In  diabetes,  inflammation  or  ulceration  may  follow  the  slightest  scratch 
or  cut,  and  the  chief  characteristics  of  a  diabetic  ulcer  are  its  rapid  spread, 
the  presence  of  considerable  inflammation  around  it,  and  often  sloughing 
of  the  tissues.  The  endarteritis  which  occurs  in  diabetes  and  the  special 
liability  of  the  tissues  in  that  affection  to  septic  infection,  have  probably 
much  to  do  with  the  rapidity  of  spread  and  the  inflammatory  condition  of 
diabetic  ulcers. 


42  ULCERATION. 

DANGERS  OF  ULCERS.— Before  dealing  with  the  treatment  of 
ulcers,  it  may  be  pointed  out  that  their  rapid  and  permanent  cure  is  a 
matter  of  great  importance,  because  not  only  is  a  patient  afflicted  with  an 
ulcer  more  or  less  incapacitated  from  work,  but  he  is  liable  to  various 
accidents  which  may  permanently  cripple  him  or  even  lead  to  his  death. 
For  example,  where  ulcers  are  situated  over  muscular  parts,  the  muscles 
may  become  so  matted  together  that  the  movements  of  the  limb  are  much 
interfered  with.  This  is  more  especially  the  case  if  the  ulcer  lies  over 
tendons;  the  tendon  and  tendon-sheath  may  then  become  adherent  to 
one  another  and  to  the  surrounding  parts.  Perhaps  the  most  common 
disabilities  resulting  from  ulceration  are  due  to  the  contraction  which  goes 
on  during  the  efforts  at  healing.  When  an  ulcer  is  situated  over  a  joint, 
for  example,  the  healing  process  may  lead  to  so  much  contraction  as 
to  permanently  fix  the  joint  in  a  faulty  (usually  a  flexed)  position.  Again, 
when  an  ulcer  completely  surrounds  the  leg,  the  contraction  may  be  such 
as  to  constrict  the  vessels  coming  from  the  parts  below,  and  so  cause  great 
and  permanent  oedema  and  often  complete  uselessness  of  the  foot.  A 
further  risk  of  an  ulcer  is  that  the  veins  in  its  vicinity  are  apt  to  become 
inflamed,  and  an  extensive  phlebitis,  simple  or  septic,  may  result.  A 
patient  with  an  open  ulcer  is  subject  to  all  the  ordinary  septic  diseases, 
more  especially  erysipelas.  And,  lastly,  it  may  be  pointed  out  that, 
where  an  ulcer  has  existed  a  long  time,  epithelioma  not  infrequently 
develops  from  it,  and  the  patient  may  die  of  this  cancerous  growth. 

TREATMENT. — In  order  to  promote  the  healing  process,  various 
principles  must  be  attended  to.  In  the  first  place,  it  is  essential  for 
rapid  healing  that  the  level  of  the  sore  should  be  nearly,  if  not  quite, 
the  same  as  that  of  the  surrounding  parts;  secondly,  its  margins  should 
be  moveable,  in  order  to  permit  of  contraction ;  and  finally,  the  granula- 
tions on  the  surface  should  be  healthy.  There  are,  therefore,  three 
practical  points  to  attend  to  in  the  treatment  of  ulcers,  (i)  To  remove 
the  various  causes  which  are  keeping  up  the  ulceration,  the  most  im- 
portant of  which  have  already  been  mentioned ;  (2)  to  improve  the 
condition  of  the  surface  and  margins  of  the  ulcer ;  (3)  to  promote 
healing  in  every  possible  way,  and  to  provide  for  the  formation  of  as 
sound  a  scar  as  can  be  obtained. 

Remove  cause. — The  first  essential,  then,  in  the  treatment  of  all 
ulcers,  is  to  seek  out  the  cause  and  remove  it.  These  causes  have  been 
sufficiently  dealt  with  in  the  foregoing  paragraphs,  and  nothing  further 
need  be  said  about  them  here. 

Rest. — In  all  cases  rest  is  absolutely  necessary.  As  has  already  been 
said,  movement  tends  to  keep  up  the  ulceration  indefinitely,  and  conse- 
quently the  patient  must  be  absolutely  prohibited  from  walking  about, 
and,  if  necessary,  the  movements  of  the  neighbouring  joints  must  be 
prevented  by  the  application  of  suitable  splints.  If  splints  are  employed, 
they  should  be  so  arranged  that  the  limb  will  be  in  the  position  most 


TREATMENT  OF  ULCERS  IN  GENERAL. 


43 


serviceable  to  the  patient  if  there  be  any  subsequent  stiffness  either  of 
joints  or  muscles.  For  example,  in  the  case  of  the  leg,  on  which  ulcers 
are  most  frequently  met  with,  it  is  well  to  apply  outside  and  inside  lateral 
splints  which  grasp  the  leg,  the  knee,  and  the  foot,  and  fix  the  ankle- 
joint  so  that  the  foot  is  at  right  angles  to  the  leg. 

Favour  the  venous  return. — Another  principle  of  the  greatest  im- 
portance is  to  favour  the  return  circulation.  The  great  danger  of 
venous  obstruction  has  already  been  insisted  upon.  It  may  lead  to  the 
transformation  of  a  simple  or  varicose  ulcer  into  a  callous  one,  and  the 
ulcer  will  refuse  to  heal  so  long  as  no  provision  is  made  for  the  proper 
return  of  blood  from  the  affected  area.  This  indication  may  be  carried 
out  in  various  ways,  but  by  far  the  most  efficient  method  is  to  place  the 
part  at  a  higher  level  than  the  heart.  Hence,  in  the  case  of  ulcers  of 
the  leg,  the  patient  should  be  put  to  bed,  the  limb  elevated  on  a  pillow, 
the  knee  and  ankle-joints  fixed,  and  the  patient  not  allowed  to  get  up 
for  any  purpose  whatever  till  cicatrization  is  complete.  Any  relaxation 
of  this  rule  will  not  only  delay  the  healing  of  the  ulcer,  but  may  lead 
to  an  extension  of  the  ulceration.  If  the  part  be  elevated,  the  venous 
return  is  greatly  favoured,  and,  even  without  any  other  treatment,  the 
exudation  which  has  been  poured  out  is  rapidly  absorbed.  As  a  result,  the 
pressure  upon  the  arterioles  going  to  the  surface  of  the  ulcer  is  removed, 
and  a  plentiful  flow  of  arterial  blood  is  again  supplied  to  it.  Thus 
rest  and  the  elevated  position  not  only  favour  the  return  of  blood  from 
the  part,  but  also  the  flow  of  blood  to  it. 

Promote  the  absorption  of  the  exudation.— Not  only  should 
the  return  of  blood  be  favoured,  but  measures  should  also  be  taken  to 
get  rid  of  the  exudation,  which  presses  on  and  interferes  with  the  circula- 
tion in  the  part.  The  elevated  position  and  rest  in  bed  are  of  themselves 
no  doubt  sufficient  to  do  this  ;  but  if  time  be  an  object,  various  measures 
may  be  taken  to  accelerate  the  absorption  of  the  exudation.  Of  these, 
one  of  the  best  is  massage.  Where  massage  is  employed  with  a  view  of 
getting  rid  of  the  thickening  around  an  ulcer,  it  should  at  first  be  applied 
to  the  parts  above  the  ulcer,  and  later  on,  as  the  skin  gets  softer  in  that 
region,  the  area  subjected  to  the  massage  may  be  increased  downwards. 
If  the  massage  were  at  first  applied  to  the  part  below  the  ulcer,  the 
absorption  would  not  be  .satisfactory,  owing  to  the  presence  of  the  exuda- 
tion above. 

Another  way  in  which  the  exudation  may  be  got  rid  of  is  by  pressure, 
and  this  plan  is  especially  useful  where  patients  will  not  lie  up.  Pressure 
may  be  applied  in  two  ways  ;  either  by  strapping,  or  by  elastic  bandages. 
The  older  plan  was  by  the  use  of  strapping,  but  it  is  not  so  good  as 
elastic  pressure.  In  employing  strapping,  strips  of  adhesive  plaster  are 
applied  fairly  tightly  around  the  ulcer  and  the  parts  in  its  vicinity.  These 
strips  should  be  about  an  inch  to  an  inch  and  a  quarter  in  breadth,  and 
rather  more  than  the  circumference  of  the  limb  in  length.  They  are 


44 


ULCERATION. 


applied  from  below  upwards,  the  centre  of  each  strip  being  applied  at 
the  point  opposite  the  centre  of  the  ulcer,  so  that  as  the  two  ends  are 
brought  together  over  the  limb  they  pull  together  the  edges  of  the  ulcer 
(see  Fig.  n).  If  the  strips  are  applied  with  the  centre  over  the  ulcer, 
the  reverse  will  be  the  case ;  when  they  are  pulled  tight  the  edges  of  the 
ulcer  will  be  separated.  The  strips  should  overlap  each  other  for  about 
tsvo-thirds  of  their  breadth,  so  that  only  about  a  third  of  each  is  exposed. 
In  this  way,  by  a  series  of  strips  of  adhesive  plaster  applied  from  below 
upwards,  the  whole  region  of  the  ulcer,  as  well  as  the  thickened  tissues 
above  and  below,  are  firmly  supported  and  pressed  upon.  Before  applying 
the  strapping  the  whole  limb  should  be  shaved,  as  otherwise  a  great 
deal  of  annoyance  is  caused  to  the  patient  when  it  is  peeled  off. 


FIG.  ii. —  STRAPPING  AN  ULCER.  To  show  how  the  plaster  should  be  applied  in 
order  to  bring  the  edges  of  the  ulcer  together  as  much  as  possible.  The  dotted  line 
indicates  the  extent  of  the  ulcer  (over  which  a  dressing  is  applied). 

One  great  objection  to  strapping  is  that  the  discharge  from  the  ulcer 
is  confined  beneath  it,  and  there  undergoes  decomposition,  with  the  result 
that  fresh  ulceration  occurs  from  the  presence  of  this  chemically  irritating 
material.  Of  course,  at  the  present  time,  one  would  naturally  disinfect 
the  ulcer  before  applying  the  strapping,  and  then  place  over  its  surface 
an  antiseptic  dressing,  such  as  boracic  lint,  so  as  to  absorb  the  fluids  and 
prevent  their  decomposition.  If  this  be  not  done  it  will  be  necessary  to 
cut  away  the  strapping  at  the  lower  part,  so  as  to  allow  the  discharge 
to  escape,  a  procedure  which  necessarily  weakens  it.  The  strapping  ought 
to  be  renewed  every  day  or  two.  It  is  well  to  renew  it  daily  if  the 
discharge  is  at  all  profuse. 


TREATMENT  OF  ULCERS  IN  GENERAL.  45 

At  the  present  time  strapping  is  generally  given  up  in  favour  of  the 
elastic  bandage,  that  known  as  Martin's  being  the  most  suitable  form. 
Martin's  bandage  is  a  thin  sheet  of  pure  rubber,  cut  into  strips  about 
three  inches  wide  and  of  varying  lengths ;  this  is  wound  around  the  limb, 
commencing  at  the  ball  of  the  toes  and  extending  up  as  far  as  the  knee. 
The  best  form  is  that  containing  a  number  of  perforations  to  permit  of 
evaporation ;  otherwise  the  perspiration  accumulates  under  the  bandage, 
and  is  apt  to  set  up  a  dermatitis.  The  bandage  is  used  both  for  those 
who  can  and  those  who  cannot  lie  up ;  when  used  by  the  latter,  it  should 
be  applied  in  the  morning  before  the  patient  gets  out  of  bed,  and  should 
be  put  on  loosely,  being  simply  rolled  spirally  around  the  limb.  The 
rubber  should  not  be  stretched  when  applied,  for  one  cannot  gauge  the 
amount  of  pressure  exerted,  and  as  the  limb  swells  when  the  patient  com- 
mences to  walk  about,  the  bandage  may  be  found  unbearably  tight.  If 
put  on  loosely,  the  oedema  which  occurs  on  walking  distends  the  bandage 
and  puts  it  on  the  stretch,  and  in  the  course  of  an  hour  or  two  it  provides 
a  fairly  satisfactory  amount  of  support.  The  bandage  should  be  removed 
when  the  patient  goes  to  bed,  thoroughly  washed  and  hung  up  to  dry ;  it 
is  a  mistake  to  wear  it  during  the  night.  When  first  introduced,  the 
rubber  bandage  was  applied  direct  to  the  surface  of  the  sore  without  any 
dressing,  but,  if  this  be  done,  the  discharge  decomposes  beneath  the 
bandage  and  prevents  healing.  Hence  the  ulcer  should  be  first  dis- 
infected and  then  a  suitable  dressing — to  be  mentioned  immediately — 
applied  beneath  the  bandage,  an  important  point  with  regard  to  the 
dressing  being  to  avoid  a  greasy  application,  as  otherwise  the  rubber  will 
be  spoilt. 

Another  method  of  getting  rid  of  the  exudation,  generally  employed 
in  the  treatment  of  callous  ulcer,  may  be  here  referred  to,  namely, 
the  application  of  blisters.  When  a  blister  is  applied  to  the  skin,  more 
blood  is  sent  to  the  part  and  the  lymph  flow  is  increased ;  and  if  a 
blister  be  applied  around  a  callous  ulcer  (the  limb,  of  course,  being  kept 
at  rest  and  in  the  elevated  position),  it  is  remarkable  how  quickly  the 
callous  condition  disappears,  and  how  soon  the  edges  become  soft  and 
in  a  condition  favourable  for  healing. 

The  essential  point  in  the  use  of  a  blister  for  ulcers  is  that  it  should 
not  be  applied  directly  over  the  raw  surface,  otherwise  the  cantharides  is 
apt  to  be  absorbed,  and  may  lead  to  serious  irritation  of  the  kidneys. 
This  must  especially  be  borne  in  mind  in  cases  of  callous  ulcer,  for  many 
of  the  patients  suffering  from  this  affection  are  the  subjects  of  Bright's 
disease.  Hence,  if  emplast.  lyttae  is  to  be  used,  a  part  corresponding  to 
the  raw  surface  of  the  ulcer  should  be  cut  away  and  the  blister  raised 
round  the  margin  only.  For  the  method  of  application  of  blisters,  see 
p.  1 8.  Usually  one  blister  will  suffice,  and  it  will  be  found  that  by  the 
time  the  blistered  surface  has  healed  the  callous  condition  of  the  ulcer 
has  disappeared,  and  its  edges  are  in  a  satisfactory  condition. 


46  ULCERATION. 

Avoidance  of  Irritation. — Another  point  which  is  common  to  the 
treatment  of  all  ulcers  is  to  get  rid  of  any  cause  of  irritation  to  the  surface 
of  the  sore.  These  causes  of  irritation  are  either  mechanical,  such  as  that 
caused  by  dressings  applied  directly  to  the  surface  of  the  sore,  or  chemical, 
such  as  unsuitable  lotions  or  decomposing  discharges  :  of  these  the  chemical 
causes  are  more  frequently  met  with.  In  order  to  avoid  mechanical  irrita- 
tion, the  dressing,  whether  it  be  gauze  or  boracic  lint,  should  not  be 
applied  directly  to  the  surface  of  the  sore,  either  oiled  silk  protective  or 
an  antiseptic  ointment  of  some  kind  being  interposed. 

A  most  important  point  in  the  treatment  of  ulcers  is  the  avoidance 
of  the  chemically  disturbing  causes :  these  may  be  either  lotions  or  decom- 
posing discharges.  The  lotions  used  must  be  non-irritating.  They  should 
of  course  be  antiseptic,  but  the  more  irritating  antiseptics  should  not  be 
selected.  It  is  too  much  the  practice  at  the  present  time  to  dress  ulcers 
with  carbolic  lotion,  and  no  more  unsuitable  application  for  a  healing 
ulcer  could  well  be  employed.  The  best  lotions  will  be  described  im- 
mediately; in  the  meantime  it  must  be  pointed  out  that  it  is  most  essential 
to  get  rid  of  the  chemical  irritation  from  decomposing  discharges. 

The  presence  of  decomposing  discharge  on  the  surface  of  an  ulcer 
interferes  very  materially  with  the  healing  process,  and  it  is  therefore  one 
of  the  most  important  points  at  the  commencement  of  the  treatment  to 
remedy,  as  far  as  possible,  the  septic  condition  of  the  sore. 

Disinfection  of  the  Ulcer. — In  order  to  do  this,  the  following  is 
the  method  of  procedure  that  we  recommend.  In  the  first  place  the 
skin,  for  a  considerable  area  around  the  ulcer,  should  be  thoroughly 
disinfected.  To  disinfect  the  surface  of  the  ulcer  alone  and  leave  the 
skin  septic  would  simply  mean  that  in  the  course  of  a  few  days  the 
surface  would  again  become  foul.  Therefore  the  skin  should  be  thoroughly 
washed  with  soap  and  water  and  all  the  hairs  shaved  off:  turpentine  is 
then  applied  to  dissolve  the  fat,  and  this  is  subsequently  removed  by 
soap  and  lotion.  The  best  lotion  is  a  1-20  watery  solution  of  carbolic 
acid,  containing  in  solution  one  five-hundredth  part  of  corrosive  sublimate ; 
this  we  shall  speak  of  hereafter  as  "strong  mixture."  The  part  is 
thoroughly  washed  with  soap  and  this  mixture,  and  then  well  scrubbed 
with  a  nail  brush  dipped  in  the  mixture,  and  after  this  is  done  the 
strong  mixture  may  be  removed  from  the  skin  by  washing  it  with 
a  1-2000  watery  solution  of  corrosive  sublimate.  As  regards  the  surface 
of  the  ulcer,  it  is  not  always  an  easy  matter  to  completely  disinfect  it 
at  one  sitting,  but  what  seems  to  be  the  best  plan  is  to  swab  it 
thoroughly  over  with  undiluted  carbolic  acid.  A  small  piece  of  sponge 
is  dipped  in  liquefied  carbolic  acid,  thoroughly  rubbed  over  the  whole 
surface  of  the  granulations  and  sides  of  the  ulcer  and  allowed  to  act 
for  some  minutes.  This  no  doubt  destroys  the  granulations;  but  these 
are  usually  unhealthy,  and  of  no  use  for  the  healing  process.  Apart 
from  this,  healing  will  not  occur  until  the  surrounding  parts  have  also 


TREATMENT  OF  ULCERS  IN  GENERAL.  47 

become  healthy,  and  no  time  is  lost  even  if  the  granulations  be  com- 
pletely destroyed.  The  carbolic  acid  causes  a  good  deal  of  pain  at  the 
time,  but  this  passes  off  in  a  minute  or  two,  for  the  acid  is  a  local  anaes- 
thetic, and  the  disinfection  is  more  thoroughly  carried  out  in  this  way 
than  in  any  other.  Where  the  granulations  are  prominent,  or  soft  and 
cedematous,  it  is  well  to  scrape  them  away  with  a  sharp  spoon ;  if  the 
ulcer  be  large  a  general  anaesthetic  is  necessary. 

Other  methods  of  purifying  the  ulcer  have  been  employed.  Lord 
Lister  used  to  apply  a  solution  of  chloride  of  zinc  (40  grains  to  the  ounce 
of  water).  This  however  is  much  more  painful  than  the  application  of  the 
undiluted  carbolic  acid,  the  pain  lasting  for  hours,  while  the  method  does 
not  seem  to  be  so  efficient. 

In  cases  where  one  does  not  wish  to  employ  undiluted  carbolic  acid, 
disinfection  of  the  sore  may  be  obtained  by  packing  the  surface  with  lint 
dipped  in  i  to  5  carbolic  oil;  if  this  be  changed  twice  a  day,  the  foul 
condition  will  usually  be  got  rid  of  in  the  course  of  two  or  three  days. 
Care  must  be  taken  that  the  oil  is  only  applied  to  the  surface  of  the  ulcer ; 
if  applied  to  the  skin  it  may  produce  much  irritation. 

First  dressing  after  disinfection. — After  the  disinfection  has  been  carried 
out  a  suitable  dressing  must  be  applied,  and  the  best  to  employ  at 
first  is  cyanide  gauze  and  salicylic  wool,  as  used  in  the  treatment  of 
wounds  (see  Chap.  VIII.).  The  cyanide  gauze  should  be  soaked  in  1-4000 
sublimate  solution  and  applied  directly  to  the  surface  of  the  ulcer,  and 
the  salicylic  wool  put  on  outside.  In  some  cases,  where  there  is  a  doubt 
as  to  the  completeness  of  the  disinfection,  it  is  well  to  pack  the  recesses 
of  the  ulcer  with  small  pieces  of  cyanide  gauze  which  have  been  lightly 
squeezed  out  of  1-2000  sublimate  solution. 

Boracic  lint  and  protective  dressing. — After  two  or  three  days,  when  the 
asepsis  of  the  part  is  assured,  and  the  tissues  are  getting  into  a  more 
healthy  condition,  the  use  of  gauze  should  be  given  up,  and  dressings  and 
lotions  employed  which  are  of  a  non-irritating  character.  The  best  lotion 
is  a  saturated  watery  solution  of  boracic  acid,  and  for  a  general  dressing  the 
best  is  the  protective  and  boracic  lint  dressing  introduced  by  Lord  Lister. 
In  this  method  the  surface  of  the  ulcer  is  washed  with  boracic  lotion,  and 
a  piece  of  protective  (oiled  silk  covered  with  a  layer  of  dextrine),  is  dipped 
first  in  carbolic  lotion  (1-20),  and  then  in  boracic  lotion  to  wash  away 
the  acid,  and  applied  over  the  wound.  The  protective  should  be  slightly 
larger  than  the  sore,  so  as  to  overlap  it  in  all  directions,  but  ought  not 
to  extend  too  far,  as  otherwise  sepsis  may  spread  in  beneath  it.  Outside 
this  protective  one  or  more  pieces  of  boracic  lint  wrung  out  of  boracic 
lotion  are  wrapped  around  the  limb,  overlapping  the  protective  to  a 
considerable  extent  in  all  directions.  This  dressing  should  be  changed 
every  day,  at  any  rate  for  the  first  few  days;  and  every  second  or  third 
day  the  skin  around  should  be  washed  with  carbolic  lotion  (i  to  20), 
care  being  taken  that  it  does  not  run  on  to  the  sore.  Once  a  week  at 


48  ULCERATIOX. 

least  the  limb  should  be  shaved.  If  there  be  much  discharge  it  is  well 
to  cut  several  holes  in  the  centre  of  the  protective  so  as  to  allow  of 
drainage  into  the  lint. 

Wet  boracic  dressing. — Where  the  ulcers  are  painful,  or  where  there  are 
sloughs  on  the  surface,  it  is  well  to  apply  wet  boracic  lint  without  any 
protective,  the  lint  being  used  in  the  same  way  as  a  water  dressing.  The 
boracic  lint  soaked  in  warm  boracic  lotion  is  applied  over  the  ulcer  so  as 
to  extend  for  a  little  distance  beyond  it,  and  outside  this,  overlapping  in 
all  directions,  is  fastened  a  piece  of  mackintosh,  oiled  silk,  or  gutta-percha 
tissue,  previously  disinfected  by  immersion  in  carbolic  lotion.  This  wet 
boracic  dressing  or  boracic  poultice,  as  it  is  sometimes  called,  should  be 
changed  twice  a  day,  but  should  not  be  continued  after  the  irritable  con- 
dition of  the  sore  has  ceased,  or  after  the  sloughs  have  separated.  If 
used  too  long,  the  granulations  become  osdematous  and  a  form  of  weak 
ulcer  is  thus  established. 


FIG.  12. — CELLULOID  WOUND  SHIELDS.  The  shield  is  inserted  in  the  centre  of  a  sheet 
of  adhesive  plaster,  by  means  of  which  it  is  applied  to  the  limb.  In  the  figures  two  holes 
are  represented  in  each  shield ;  these  are  to  permit  of  evaporation.  If  it  be  desired  to 
keep  the  surface  of  the  ulcer  quite  moist,  non-perforated  shields  may  be  used. 

Boracic  ointment. — Another  method  of  dressing  that  is  especially  useful 
where  the  ulcers  are  healing  rapidly,  is  the  application  of  various  ointments. 
Of  course  these  must  be  antiseptic ;  zinc  ointment,  which  is  commonly 
employed,  being,  on  account  of  its  septicity,  a  very  objectionable  dressing 
for  a  wound.  The  best  is  either  unguentum  boracis  or  unguentum  eucalypti. 
The  boracic  ointment  of  the  Pharmacopoeia  will  however  be  found  to  be 
too  strong  to  permit  rapid  healing,  and,  in  most  cases,  one  of  a  quarter 
its  strength  is  the  most  suitable.  This  should  be  spread  on  muslin  or 
butter-cloth,  in  a  thin  even  layer,  no  portion  of  the  surface  being  left 
uncovered  by  the  ointment,  and  before  application  it  is  well  to  dip  it  in 
the  boracic  solution.  Outside  the  ointment  a  piece  of  boracic  lint  is 
applied  and  the  whole  secured  by  a  bandage. 

Cases  are  sometimes  met  with  where  the  surface  of  the  sore  is  extremely 
delicate  and  seems  to  resent  the  presence  of  any  application,  however 
unirritating  it  may  be.  As  long  as  there  is  anything  in  contact  with  it,  cica- 
trization will  not  take  place.  Under  these  circumstances,  the  best  plan  is 
to  dispense  entirely  with  dressings  and  merely  to  place  over  the  ulcer  some 


TREATMENT  OF  ULCERS  IN  GENERAL. 


49 


contrivance  that  will  prevent  anything  coming  into  contact  with  its  surface. 
This  may  be  accomplished  by  fixing  over  it  a  perforated  celluloid  shield 
(see  Fig.  12)  of  suitable  size  and  shape,  leaving  the  granulating  surface 
bare.  The  shield  should  be  removed  two  or  three  times  daily,  and  the 
raw  surface  washed  with  boracic  lotion  to  remove  any  discharge.  The  limb 
should  of  course  be  fixed  in  the  elevated  position,  and  the  method  of 
disinfection  of  the  surrounding  skin  recommended  above  should  be  carried 
out  before  the  shield  is  applied.  If  there  is  much  tendency  to  the  formation 
of  crusts  from  the  drying  of  the  discharge,  it  is  well  to  apply  a  moist  dressing 
outside  the  shield  to  prevent  evaporation.  A  piece  of  cyanide  gauze,  soaked 
in  boracic  lotion  and  covered  with  mackintosh,  applied  over  and  around  a 
celluloid  shield  of  suitable  size  and  shape,  or  a  wire  cage,  moulded  to  fit 
the  limb,  will  usually  suffice,  the  limb  being  suspended  in  a  cradle. 

Skin-grafting  to  obtain  a  sound  scar. — A  further  object  in  the 
treatment  of  all  ulcers  is  to  obtain  a  scar  that  is  as  sound  as  possible. 
In  the  case  of  ulcers  affecting  the  lower  extremity,  especially  in  elderly 
people,  the  scar  obtained  when  the  ulcer  is  allowed  to  heal  of  itself  is 
weak,  and  readily  breaks  down  if  the  patient  does  much  standing  or 
walking.  The  result  is  that  every  now  and  then  the  patient  must  give  up 
his  work  in  order  to  get  the  ulcer  re-healed,  or  must  be  content  to  employ 
means  which  merely  prevent  the  extension  of  the  ulcer,  and  only  relieve 
him  of  some  of  his  discomfort.  Where  the  best  possible  scar  is  desired, 
and  where  it  is  important  to  avoid  any  great  contraction,  it  is  necessary 
to  adopt  one  of  the  methods  of  skin-grafting.  There  are  three  plans  by 
which  the  rapid  healing  of  a  sore  may  be  brought  about :  Reverdin's 
epidermis  grafting,  Thiersch's  skin-grafting,  and  the  use  of  the  whole 
thickness  of  the  skin ;  of  these  the  best  in  our  opinion  is  that  employed 
by  Thiersch. 

In  Reverdin's  method  small  thin  portions  of  the  superficial  layer 
of  the  skin  are  snipped  off  by  curved  scissors.  Pieces  about  the  size 
of  a  hemp  seed  are  planted  on  the  surface  of  the  granulations  at  short 
distances  from  each  other ;  epidermic  growth  occurs  from  each  of  these 
little  points,  and  the  result  is  that  numerous  small  islands  of  epithelium 
form  over  the  surface  of  the  sore.  If  the  grafts  are  close  enough  together 
and  the  other  conditions  of  healing  are  favourable,  these  islands  of  epi- 
dermic growth  soon  coalesce,  and  in  this  way  rapid  cicatrization  is  obtained. 
It  is  necessary  that  these  grafts  should  not  be  too  far  apart,  because,  as  a 
rule,  they  have  only  a  limited  power  of  reproduction.  Usually  each  graft 
gives  rise  to  an  island  of  epidermis  about  the  size  of  a  sixpence,  and  then 
growth  seems  to  come  to  a  standstill.  The  result  of  this  method  of 
epidermic  grafting  is  that  rapid  healing  is  obtained  in  many  cases,  more 
especially  in  burns  and  sores  on  the  trunk,  where  the  skin  is  freely  move- 
able  over  the  deeper  parts.  Further,  the  contraction  of  the  subsequent 
cicatrix  is  considerably  diminished,  because  less  granulation  tissue  is  formed 
than  if  the  sore  has  to  heal  altogether  from  the  margin,  and  the  amount 

D 


50  ULCERATION. 

of  contraction  depends  entirely  on  the  amount  of  young  granulation 
tissue  produced.  Nevertheless,  a  considerable  amount  of  contraction  will 
inevitably  occur  where  healing  has  been  obtained  in  this  way,  and  the 
resulting  scar  is  not  materially  stronger  than  that  obtained  by  permitting 
the  sore  to  heal  from  the  edge. 

With  a  view  of  obtaining  a  sounder  scar,  much  more  extensive  and 
thicker  portions  of  the  skin  must  be  taken,  and  the  grafts  must  be  applied 
close  together.  There  are  two  ways  of  doing  this  :  either  by  using  the 
whole  thickness  of  the  skin,  or  by  employing  Thiersch's  method,  in  which 
about  half  the  thickness  of  the  skin  is  shaved  off.  We  need  not  describe 
the  procedure  where  the  whole  thickness  of  the  skin  is  employed,  partly 
because  the  results  are  not  satisfactory,  and  partly  because  all  the  con- 
ditions for  which  it  was  introduced  are  far  better  fulfilled  by  Thiersch's 
method. 

Thiersch's  method.  —  In  employing  Thiersch's  method,  the  skin  which 
is  to  be  used  for  the  grafting  must  first  be  thoroughly  disinfected  in  the 
usual  manner,  namely,  by  turpentine,  soap  and  strong  mixture,  and  it 
must  also  be  carefully  shaved.  The  presence  of  hairs  on  the  grafts  seems 
to  materially  interfere  with  their  union.  The  skin  of  the  front  of  the  thigh 
or  the  flexor  surface  of  the  fore-arm  is  usually  employed  for  the  purpose. 

Preparation  of  Ulcer.  —  (a)  Preliminary.  —  The  sore  itself  must  also  be 
prepared  beforehand.  It  is  of  no  use  to  graft  a  sore  which  is  actually 

ulcerating  ;  it  must  be  brought  into  a 
healthy  condition,  and  healing  must 
have  commenced  before  grafting  is 
likely  to  be  successful.  The  best 
criterion  that  healing  is  taking  place 
is  the  presence,  at  the  edges,  of  the 
dry  red  line  which  indicates  recently 
formed  epithelium.  Some  surgeons  wait 
for  a  considerably  longer  time  before 
Drafting,  in  order  to  get  a  firm  layer 

FIG.    13.—  THIERSCH  s    METHOD   OF    SKIN-        °  ' 

GRAFTING.  Ulcer  prepared  for  grafting.  The  of  granulations,  but  OUr  experience  is 
newly  healed  edge  has  been  cut  away,  and  the 


surface  has  been  scraped  till  all  the  granulations         that,    aS    SOOn    as    healing    begins 
have    been    removed    and    the   firmer    layer    of 

newly  formed  fibrous  tissue  exposed.  the  edge,  the  sore  may  be  safely  grafted 

upon.     A  second  essential  is  that   the 

sore  shall  be  aseptic.  If  it  is  suppurating,  and  the  discharges  are  septic, 
the  graft  —  which  is  after  all  merely  a  piece  of  dying  tissue  —  will  become 
impregnated  with  decomposing  pus,  and  will  rapidly  become  loosened, 
die,  and  undergo  decomposition.  The  methods  of  rendering  the  ulcer 
aseptic  have  already  been  described  (see  p.  46). 

(b)  Operative.  —  With  a  sore  that  is  aseptic  and  beginning  to  heal,  the 
following  is  the  method  of  procedure.  The  patient  having  been  put 
under  an  anaesthetic,  the  granulations  over  the  whole  surface  of  the  ulcer 
are  evenly  scraped  away,  taking  care,  however,  only  to  remove  the  soft 


TREATMENT  OF  ULCERS  IN  GENERAL.  5! 

layer  of  granulations  and  not  to  go  through  the  deeper  one  of  newly 
formed  fibrous  tissue  into  the  fat.  A  surface  is  thus  left  which  is  smooth, 
highly  vascular,  and  firm,  and  consists  of  the  deeper  layers  of  granulation 
tissue  which  have  already  become  organized  into  fibrous  tissue  (see  Fig.  13). 
In  ulcers  on  the  lower  extremity,  it  is  also  of  the  greatest  importance  to 
remove  those  portions  of  the  edge  which  have  already  become  covered  with 
new  epithelium.  One  is  tempted  to  limit  the  skin-grafting  to  the  parts 
actually  unhealed,  but  if  this  be  done  the  result  will,  as  a  rule,  be  very  dis- 
appointing, for,  while  the  part  that  has  been  grafted  remains  perfectly  sound, 
the  margin  where  spontaneous  healing  had  occurred  is  very  likely  to  break 


FIG.   14. — THIERSCH'S  METHOD  OF  SKIN-GRAFTING.      Cutting  the  grafts.      To  show 
how  the  parts  are  steadied  while  the  grafts  are  being  cut. 

down,  and  thus  a  narrow  line  of  ulceration  appears  later  on  at  the  site  of 
the  edge  of  the  ulcer.  Having  then  removed  the  layer  of  granulations  in 
the  manner  described,  and  cut  away  the  newly  healed  edge  of  the  ulcer  (as 
shown  in  Fig.  13),  the  next  thing  is  to  arrest  the  bleeding  completely  before 
applying  the  grafts.  This  is  best  done  by  pressure,  but,  if  pressure  be 
applied  directly  to  the  sore  either  by  sponges  or  dressings,  it  will  be  found 
that  the  bleeding  begins  again  when  they  are  removed,  because  they  stick 
to  the  raw  surface.  The  best  plan  is  to  interpose  a  piece  of  protective 
(see  p.  47),  which  prevents  adhesion  of  the  sponges  to  the  sore  and  thus 
avoids  a  renewal  of  the  bleeding  on  removal.  Hence,  when  the  scraping 
and  cutting  are  finished,  any  spouting  vessel  is  clamped,  and  a  large  piece 
of  protective  dipped  in  the  1-2000  sublimate  solution  is  applied  over  the 
raw  surface.  Outside  this  several  sponges  are  placed,  and  a  bandage 


52  ULCERATION. 

dipped  in   1-2000  sublimate  solution  is   firmly  bound  over  them,  or,  if  the 
sore  be  small  and  an  assistant  available,  he  may  apply  the  pressure. 

Cutting  the  Grafts. — While  the  bleeding  is  being  arrested  by  pressure, 
the  surgeon  proceeds  to  cut  his  skin-grafts.  In  Thiersch's  method  the 
grafts  may  be  taken  from  any  part  of  the  body,  but  as  a  rule  they  are 
most  conveniently  cut  from  the  front  of  the  thigh.  The  skin  having  been 
disinfected  (see  p.  46),  the  surgeon  grasps  the  thigh  from  behind  with  his 
left  hand,  keeping  the  skin  as  tense  as  possible  and  also  making  it  prominent 
and  flat  by  pushing  the  muscles  and  skin  forwards  from  the  bone.  This 
is  shown  in  Fig.  14.  The  skin  is  further  put  on  the  stretch  vertically  by 
an  assistant  who  pulls  it  upwards  at  the  groin  and  downwards  at  the  knee. 
The  razor  (shown  in  Fig.  15),  which  should  have  a  very  broad  blade,  is 
dipped  in  boracic  lotion  and  is  constantly  kept  wet  by  this  solution  whilst 
the  grafts  are  being  cut,  just  as  in  making  microscopical  sections  of  fresh 
tissues.  If  this  irrigation  be  not  maintained,  the  graft  tends  to  adhere  to 
the  razor  and  may  be  either  partially  or  wholly  cut  through  before  a 
sufficient  length  has  been  obtained.  The  razor  is  made  to  penetrate 
through  about  half  the  thickness  of  the  skin,  and  then,  by  a  lateral 


FIG.  15. — THIERSCH'S  METHOD  OF  SKIN-GRAFTING.  Special  razor  for  cutting  grafts. 
The  handle  is  ir.etal  and  the  blade  is  short  and  very  wide.  In  using  it,  it  will  be  found 
most  convenient  to  grasp  it  with  the  blade  and  the  handle  in  the  same  straight  line  (see 
Fig.  14). 

sawing  motion,  the  grafts  are  cut  as  broad  and  as  long  as  possible.  After 
a  little  practice  it  is  easy  to  cut  grafts  about  two  inches  in  breadth,  and 
six  or  seven  in  length.  If  one  graft  is  not  sufficient,  it  is  best  simply  to 
slide  it  off  the  razor  and  leave  it  lying  on  the  bleeding  surface ;  in  this 
way  it  is  kept  warm  and  moist.  Some  surgeons  put  the  graft  into  warm 
saturated  boracic  lotion,  and  it  is  then  said  to  spread  out  more  easily 
afterwards,  but  by  the  former  plan,  the  tissues  lie  in  their  own  juices  and 
the  cells  are  more  likely  to  retain  their  full  activity. 

Application  of  Grafts. — When  a  sufficient  number  of  grafts  have  been 
cut,  the  bandage,  sponges,  and  protective  are  removed  from  the  wound 
and,  if  the  bleeding  has  quite  stopped,  as  is  generally  the  case,  the  grafts 
are  applied  to  its  surface.  The  latter  usually  has  a  thin  layer  of  blood 
clot  upon  it,  and  this  should  be  gently  wiped  away.  Each  graft  is  lifted 
with  forceps  or  the  fingers,  and  placed  on  the  sore  with  the  cut  surface 
downwards,  and  then,  by  means  of  a  couple  of  probes,  the  folds  of  the 
graft  are  carefully  undone,  and  it  is  stretched  evenly  over  the  surface  (see 
Fig.  16).  The  grafts  should  overlap  the  edges  of  the  skin  and  also  each 


TREATMENT  OF  ULCERS  IN  GENERAL. 


53 


other,  so  that  no  part  of  the  raw  surface  is  left  exposed,  for  granulations 
always  spring  up  on  the  uncovered  parts,  and  are  apt  to  eat  away  the 
grafts  in  their  vicinity;  furthermore  a  thin  scar,  which  may  subsequently 
break  down,  is  left  at  these  points.  The  graft  is  always  thinner  at  the 
edge  than  at  the  centre,  and  it  is  these  thin  edges  which  overlap  each 
other  or  the  edge  of  the  ulcer;  there  is  no  real  sloughing  of  these  over- 
lapping edges. 

Dressing. — In  spreading  out  the  graft,  it  will  be  found  that  air  bubbles 
collect  beneath  it,  and  also  that  some  amount  of  oozing  goes  on,  and  the 
bubbles  and  clot  may  prevent  complete  adhesion  of  the  graft.  Hence 
the  next  procedure  is  to  get  rid  of  them  by  pressure.  If  that  be  attempted 


\ 


FIG.   16. — THIERSCH'S  METHOD  OF  SKIN-GRAFTING.     Spreading  the  grafts  out  upon 
the  raw  surface.     The  overlapping  of  the  grafts  is  also  shown. 

by  means  of  sponges  or  the  hands,  the  graft  is  apt  to  be  displaced. 
The  following  is  the  best  plan :  strips  of  protective  about  an  inch  in 
breadth,  and  long  enough  to  overlap  the  edges  of  the  wound,  purified 
in  1-20  carbolic  lotion  and  subsequently  rinsed  in  boracic  lotion,  are 
applied  firmly  over  the  grafted  surface,  beginning  at  the  lower  part.  Each 
strip  should  overlap  the  one  below,  just  as  in  the  case  of  strapping,  and 
they  should  extend  well  on  to  the  skin  at  each  end  (see  Fig.  17).  If 
each  strip  as  it  is  put  on  be  grasped  by  the  two  ends  and  firmly  pressed 
down  on  the  limb,  the  pressure  thus  applied  suffices  both  to  expel  the  air- 
bubbles  and  blood,  and  also  to  arrest  further  capillary  oozing.  The  whole 
surface  of  the  skin-grafts  being  thus  covered,  ordinary  cyanide  gauze 
wrung  out  of  1-4000  sublimate  solution  is  applied,  with  salicylic  wool 
outside  it.  The  limb  should  afterwards  be  placed  upon  a  splint,  of  at 
any  rate  so  fixed  that  movement  cannot  occur  during  the  progress  of 
healing. 

The  place  from  which  the  grafts  have  been  taken  may  also  be  dressed 
with  the  protective  and  gauze  dressing,  which  need   not  be  disturbed  for 


54 


ULCERATION. 


ten  days  or  a  fortnight.  At  the  end  of  that  time  the  whole  surface  will 
usually  be  healed,  unless  the  razor  has  somewhere  gone  a  little  deeper 
than  is  necessary.  If  healing  be  not  quite  complete,  weak  boracic  ointment 
may  be  applied.  The  limb  from  which  the  grafts  are  taken  should  always 
if  possible  be  the  same  as  that  on  which  is  the  ulcer  requiring  grafting ;  for 
example,  when  the  ulcer  is  on  the  leg,  the  grafts  should  be  taken  from  the 
thigh  of  the  same  side.  Unless  this  be  done,  a  second  splint  will  be 
required  to  fix  the  limb  from  which  the  grafts  have  been  taken,  until 
healing  is  complete. 


FIG.  17.— THIERSCH'S  METHOD  OF  SKIN-GRAFTING.  Application  of  protective.  The 
wound  is  represented  by  the  dotted  line,  and  the  strips  of  protective  overlapping  one 
another  and  the  edges  of  the  wound  are  shown  in  position. 

Changing  first  Dressing. — The  dressing  should  be  left  on  the  grafted 
surface  for  about  five  days;  in  some  cases  it  may  even  be  left  for  a 
week.  If  the  wound  be  aseptic,  no  suppuration  or  decomposition  takes 
place  beneath  it.  While  removing  the  dressing,  it  should  be  thoroughly 
soaked  with  a  1-2000  sublimate  solution,  for  the  protective  may  stick  at 
the  edge  and  adhere  to  a  graft,  which  may  thus  be  peeled  off  unless  great 
care  be  taken.  The  parts  should  be  gently  cleansed  with  a  1-2000  sublimate 
solution,  and  it  is  best  to  re-apply  the  protective  and  gauze  dressing  for 
about  another  week.  At  the  end  of  that  time  the  grafts  are  fairly  firmly 
adherent,  and  then  an  antiseptic  ointment — preferably  the  quarter-strength 
boracic — is  the  best  application. 

After-treatment. — It  will  be  found  that,  even  at  the  first  dressing,  the 
grafts  present  a  pink  colour  and  are  adherent  to  the  deeper  surface, 
though  they  are  still  readily  detached.  In  the  course  of  about  a  week 
the  old  epidermis  peels  off,  but  no  raw  surface  is  left.  Later  on  there 
is  a  great  tendency  to  the  formation  of  new  epithelium,  cornification  and 
drying  up,  and  it  is  in  avoiding  the  latter  condition  that  ointments  are  so 
useful.  In  fact,  till  the  scar  is  absolutely  sound,  it  is  well  to  keep  the 
surface  covered  with  some  greasy  application,  the  best  being  the  quarter- 
strength  boracic  ointment. 


TREATMENT  OF  ULCERS  IN  GENERAL.  55 

Time  required  for  cure. — A  very  important  point  to  decide  is  when 
the  patient  may  be  allowed  to  walk  about  after  an  ulcer  of  the  leg  has 
been  skin-grafted.  If  he  begins  too  soon,  the  grafts  will  almost  certainly 
become  detached.  That  this  will  be  so,  is  evident  from  a  consideration 
of  the  mode  in  which  the  adhesion  of  the  grafts  takes  place.  At  first 
they  adhere  to  the  surface  of  the  sore  simply  by  means  of  the  effused 
and  coagulated  lymph.  Cells  very  rapidly  spread  into  this  lymph,  and, 
in  the  course  of  two  or  three  days,  the  space  between  the  graft  and  the 
raw  surface  is  occupied  by  a  mass  of  young  cells.  In  this  tissue  young 
blood  vessels  develop,  and  penetrate  into  the  grafts,  whilst,  at  the  same 
time,  the  cells  of  the  grafts  grow  and  assist  in  the  development  of 
the  young  tissue  and  of  the  blood-vessels.  Thus  the  graft  becomes 
vascularized,  but  for  a  considerable  time  the  tissue  between  it  and  the 
surface  of  the  sore  contains  many  young  blood-vessels  with  delicate 
walls,  and  therefore,  if  the  patient  stands  erect  and  allows  the  pressure  of 
the  column  of  blood  to  tell  on  these  vessels,  they  rupture,  and  bleeding 
occurs  beneath  the  graft  and  leads  to  its  detachment.  It  requires  a  long 
time  before  the  graft  is  firmly  incorporated  with  the  tissue  beneath,  by 
the  development  of  elastic  fibres ;  indeed,  it  may  be  reckoned  that  this 
union  is  not  complete  until  from  three  to  six  months  have  elapsed.  Cer- 
tainly up  to  three  months  the  graft  will  in  all  probability  be  destroyed  if 
the  patient  walks  about.  Hence,  unless  that  time  can  be  devoted  to  the 
treatment,  it  is  not  worth  while  employing  skin-grafting  for  ulcers  of  the 
lower  limbs.  By  this,  however,  it  is  not  implied  that  it  is  necessary  to  keep 
the  patient  in  bed  for  the  whole  time,  but  merely  that  the  foot  must  not  be 
allowed  to  hang  down,  nor  must  any  weight  be  borne  upon  it.  At  the  end 
of  about  six  weeks  the  patient  may  be  allowed  to  get  up  and  lie  on  a  sofa 
or  sit  up  with  the  leg  on  another  chair,  but  it  must  not  be  permitted  to 
hang  down.  At  the  end  of  about  three  months  he  may  be  allowed  to 
get  about,  but  in  order  to  prevent  the  detachment  of  the  grafts,  he  should 
be  fitted  with  a  knee  rest  and  peg  on  which  he  walks,  the  leg  projecting 
out  behind  him.  If  possible  he  should  not  put  his  foot  to  the  ground 
till  five  or  six  months  have  elapsed. 

Of  course,  in  cases  of  sores  on  other  parts  of  the  body,  where  the 
erect  posture  does  not  cause  congestion  of  the  parts,  the  patient  may  be 
allowed  to  walk  about  almost  from  the  first,  certainly  after  the  first 
three  weeks. 

Results. — The  scar  which  results  after  skin-grafting  performed  in  this 
manner  is  of  a  highly  satisfactory  character,  and  by  its  means  ulcers  which 
have  been  intractable  for  years  may  be  firmly  and  satisfactorily  closed,  with 
very  little  tendency  to  break  down  subsequently ;  but  in  order  to  obtain 
that  result,  the  period  of  rest  prescribed  must  be  carefully  attended  to. 

Treatment  where  Patients  cannot  lie  up. — The  surgeon  has  also  to 
treat  ulcers  in  the  Out-patient  department  of  Hospitals,  where  the  measures 
above  referred  to  cannot  be  employed,  as  the  patient  is  unable  to  afford 


56  ULCERATION. 

the  necessary  time,  and  the  question  then  arises,  what  is  best  to  be  done? 
In  the  first  place,  one  cannot  expect  to  cure  the  ulcer,  though  in  some 
rare  cases  the  ulcer  does  heal ;  in  the  majority,  however,  even  though 
it  may  be  somewhat  improved,  it  remains  open.  Nevertheless  a  good  deal 
may  be  done  to  alleviate  the  patient's  troubles  and  to  prevent  the  further 
spread  of  the  sore.  In  treating  out-patients  it  is  impossible  to  get  rid  of 
the  dependent  position  of  the  limb  and  the  bad  results  it  produces,  but 
these  may  be  mitigated  by  giving  as  much  support  to  the  circulation  as 
possible ;  the  septic  condition  of  the  wound  can  also  be  got  rid  of. 

These,  then,  are  the  two  points  which  are  to  be  aimed  at  in  the 
"  ambulatory  "  treatment  of  ulcers  of  the  leg — support  of  the  circulation 
and  asepsis  of  the  sore.  The  asepsis  of  the  sore  is  carried  out  on  the 
lines  already  described  (see  p.  46),  and  the  method  need  not  be  repeated 
here.  As  to  the  support  of  the  circulation,  the  most  popular  method  is 
by  the  use  of  Martin's  rubber  bandage,  the  mode  of  application  of  which 
has  been  already  detailed  (see  p.  45).  Still  better  than  Martin's  rubber 
bandage,  and  what  we  would  advise  in  the  first  instance,  is  the  method 
introduced  by  Unna,  and  known  as  Unnds  bandage.  This  is  a  bandage 
stiffened  with  gelatine,  and  its  advantages  are  that  the  patient  cannot 
meddle  with  the  sore,  and  that  it  gives  a  uniform  elastic  support  without 
unnecessary  pressure;  it  is  applied  in  various  ways. 

The  method  we  prefer  is  as  follows.  In  the  first  place,  the  sore  and 
skin  around  are  thoroughly  disinfected,  and  a  dressing  of  protective  and 
boracic  lint  applied.  Later  on  weak  boracic  ointment  may  be  substituted, 
or  protective  and  gauze  may  be  used  for  a  few  days.  After  the  sore  has 
been  properly  purified,  a  mixture  consisting  of  40  parts  of  water,  40  of 
glycerine,  10  of  gelatine,  and  some  oxide  of  zinc  to  make  it  stiffer,  is 
applied  to  the  outside  of  the  dressing.  This  material  becomes  solid  at 
the  ordinary  temperature,  but  is  readily  liquefied  by  gentle  heat.  The 
liquefied  material  is  rubbed  over  the  outside  of  the  dressing,  and  a 
double-headed  bandage  is  put  on,  beginning  over  the  centre  of  the  ulcer, 
one  roll  going  downwards  towards  the  toes  and  the  other  upwards  towards 
the  knee.  This  bandage  is  applied  smoothly  and  not  tightly,  the  melted 
mixture  is  then  rubbed  into  it,  and  before  it  sets  another  bandage  dipped 
in  hot  water  is  applied  over  it.  This  arrangement  dries  in  a  very  short 
time  and  forms  a  firm,  elastic,  and  at  the  same  time  not  too  heavy  support 
to  the  limb,  and  thus  some  of  the  disadvantages  of  other  dressings,  more 
especially  the  irregularity  of  the  pressure  which  often  occurs  in  a  self- 
applied  Martin's  bandage,  are  avoided.  If  possible,  Unna's  bandage  should 
be  put  on  early  in  the  day  before  the  leg  has  swollen  from  walking  about. 
The  dressing  should  be  changed  according  to  the  amount  of  discharge 
present;  usually  at  first  every  other  day,  but,  as  the  discharge  diminishes, 
at  less  frequent  intervals.  It  is  readily  removed  by  putting  the  leg  in  a 
tub  of  warm  water  so  as  to  melt  the  gelatine,  and  the  bandages  can 
then  be  unwound  quite  easily.  In  cases  where  the  ulcer  has  healed  the 


TREATMENT  OF  INDIVIDUAL  ULCERS. 


57 


parts  should  be  supported  for  some  time  by  Unna's  bandage ;  massage 
should  also  be  used,  more  especially  if  the  scar  be  hard  and  fixed 
and  the  muscles  atrophied.  The  legs  should  be  frequently  immersed  in 
a  warm  bath  and  lanoline  rubbed  into  the  skin  so  as  to  soften  the 
epidermis. 

Special  points  in  the  treatment  of  the  various  forms  of  Ulcer.— 
The  foregoing  remarks  as  to  treatment  apply  to  all  ulcers,  but  it  will  now 
be  well  to  mention  certain  points  peculiar  to  the  treatment  of  the  individual 
forms. 

(1)  Simple  Ulcer. — The  simple  ulcer  is  one  that  is  prevented  from  healing 
by  various  local  causes  not  usually  of  a  serious  character.     The  chief  of 
these  are  standing  and  walking,   especially  if  varicose  veins  are  present  or 
the   patient   is   advanced  in  years.     If  these  causes  be  removed,  and  the 
limb  placed  at  rest  in  a  suitable  position,  the  sore  will  quickly  heal.     In 
the  treatment  of  a   simple  ulcer,  then,  the  patient  should  be  put  to  bedr 
the  leg  elevated  on  a  pillow,  and  fixed  if  necessary,  and  suitable  dressings 
applied  to  the  part.      It  is  well  to  disinfect  the  surface  of  the  ulcer  (see 
p.  46),  but  where  the  surface  is  comparatively  healthy  it  is  hardly  neces- 
sary to  destroy  the  granulations  by  means  of  pure  carbolic  acid ;  in  such 
instances,  powdering  the  sore  with  iodoform  will  usually  suffice.     The  best 
dressing   is   the   quarter-strength    boracic   ointment,    used   as    described    on 
p.  48,  and  changed  either  every  day  or  every  alternate  day.      When   the 
ulcer  is  large,  and  especially  if  the  patient  be  old,  skin-grafting  (see  p.  50) 
should  be  employed  with  a  view  of  obtaining  a  permanent  cure. 

(2)  Inflamed  Ulcer. — Here  there  is  not  only  ulceration  but  also  acute 
inflammation,  and  both   conditions  require  treatment.     The  patient  should 
be  put   to   bed   with   the  leg   elevated,  and  warm  antiseptic  fomentations 
applied.      The    best    of    these    is    boracic    lint    dipped    in    warm    1-4000 
sublimate  solution  or    boracic  lotion,   applied  wet  over  the  ulcer  and   the 
skin  in  the  vicinity,  and  overlapped  in  all  directions  by  gutta-percha  tissue  or 
mackintosh.     This  dressing  should  be  changed  twice  a  day  at  least,  and  oftener 
if  the  inflammation  be  severe  or  the  pain  acute.    Before  doing  this  it  is  well  to 
disinfect  the  surface  of  the  sore   by  the   application  of  undiluted   carbolic 
acid,  and  then  to  powder  it  with  iodoform  once  or  twice  a  day  for  a  few 
days.      Another  important   point   is  local   depletion.      We   have  previously 
mentioned  the  fact  (see  p.  39)  that  where  these  ulcers  are  multiple  they 
are  separated  by  bridges  of  skin,  which  are  much    swollen  and   inflamed, 
and  are  prone  to  become  gangrenous.     The  division  of  these  bridges  will 
often  prevent  the  impending  gangrene,  and  the  consequent  loss  of  tissue, 
while  at  the  same   time  it   allows  the   escape  of  exudation   and  of  blood, 
and  so  improves  the   inflammatory  condition.       Even    where   these  bridges 
of  skin   are   not   present,    considerable    improvement   will   be    obtained    in 
an  ulcer  of  this  kind  by  making  incisions  into  the  inflamed  tissues  around, 
the  cuts  radiating  from  the  centre  of  the  ulcer.     When  the  inflammation  has 
subsided    the    treatment    is    that    of  a    healing    sore.      (Boracic   ointment 


58  ULCERATION. 

treatment,  see  p.  48.)  Skin-grafting  (see  p.  50)  will  be  called  for  where 
the  ulcer  is  large. 

(3)  Weak  Ulcer. — In  the  case  of  a  weak  ulcer  the  cause  of  the  weakness 
(see  p.  39)  must  be  sought  for  and  removed.  If  general  anaemia  be  the 
cause,  it  should  be  treated  by  iron,  best  administered  in  the  form  of 
Blaud's  capsules,  commencing  with  doses  of  five  grains  three  times  a  day. 
While  iron  is  the  best  drug  to  use  in  ordinary  cases  of  anaemia,  some 
cases,  especially  of  the  graver  chlorotic  form,  yield  more  quickly  and 
satisfactorily  to  arsenic,  and  therefore,  if  the  iron  does  not  seem  to  suit, 
liquor  arsenicalis  should  be  substituted  for  it,  beginning  with  doses  of  three 
minims  after  food  twice  a  day,  and  increasing  the  dose  by  one  minim  every 
third  or  fourth  day  up  to  twelve  minims  or  more.  The  medicinal  treatment 
must,  of  course,  be  accompanied  by  nourishing  diet  and  good  hygienic 
conditions.  Where  the  cause  of  the  weakness  of  the  ulcer  is  oedema  from 
heart  or  kidney  disease,  treatment  suitable  to  these  affections  must  be 
employed. 

Of  local  conditions  one  of  the  first  things  that  should  be  looked 
for  is  difficulty  in  the  contraction  of  the  sore.  This  may  result  from  ad- 
hesion to  the  deeper  parts,  from  the  hardness  of  the  tissues  around  the 
sore,  as  in  the  callous  ulcer,  or  from  the  size  of  the  original  sore  and  the 
large  amount  of  cicatricial  tissue  formed  during  healing,  etc.  If  due  simply 
to  the  denseness  of  the  scar,  apart  from  exudation  into  the  tissues,  lateral 
incisions  through  the  sound  parts  beyond  will  sometimes  allow  the  ulcer  to 
heal.  Where  the  latter  is  adherent  to  bone  it  should  be  detached,  portions 
of  the  thickened  margin  cut  away,  the  surface  scraped  with  a  sharp  spoon, 
and  skin-grafting  employed.  In  some  instances  portions  of  bone  have  been 
removed,  or  joints  have  been  excised  to  allow  of  contraction  taking  place ; 
but  this  is  very  rarely  necessary,  especially  since  the  introduction  of 
Thiersch's  method  of  skin-grafting.  In  every  case  of  weak  ulcer,  the 
part  must  of  course  be  kept  at  rest  in  the  elevated  position,  and  the  weak 
granulations  should  be  destroyed.  The  best  way  of  doing  this  is  to  scrape 
them  away  and  apply  undiluted  carbolic  acid  to  the  raw  surface,  thus  dis- 
infecting the  ulcer  at  the  same  time. 

Where,  in  a  sore  which  has  been  rendered  aseptic,  the  granulations 
become  exuberant,  they  should  be  clipped  off  and,  after  the  oozing  has 
stopped,  the  surface  rubbed  with  nitrate  of  silver.  Should  there  be  ex- 
cessive growth  of  the  granulations  afterwards,  they  may  be  kept  down  by 
repeated  applications  of  solid  nitrate  of  silver  or  sulphate  of  copper  made 
daily,  or  every  other  day.  Care  must  be  taken  not  to  apply  this  to  the 
healing  edge. 

Various  stimulant  applications  are  usually  advised  for  weak  ulcers,  such 
as  solutions  of  sulphate  of  zinc  (the  so-called  red  lotion),1  or  sulphate  of 
copper  in  a  strength  of  two  grains  to  the  ounce  of  water.  These  are 

1  The   formula   for    "Red    Lotion"   is   as   follows:    Zinci   sulphatis,    gr.    xx  ;    Spiritus 
Rosmarini ;   Spiritus  Lavandulse,  aa  5»j  '•>   Aquse   ad  Oj. 


TREATMENT  OF  INDIVIDUAL  ULCERS.  59 

chiefly  of  use  in  that  form  of  weak  ulcer  where  the  surface  is  quite  inactive 
and  shows  few  and  imperfect  granulations.  They  are  useless  in  the  cases 
with  exuberant  or  cedematous  granulations.  It  is  doubtful  how  far  benefit 
results  from  these  applications,  and  they  are  not  to  be  recommended  in  the 
ordinary  treatment  of  ulcers,  and  should  only  be  used  in  the  particular 
form  of  weak  ulcer  to  which  we  have  alluded,  and  which  is  most  often 
associated  with  general  anaemia.  Where  the  sore  is  cedematous,  the 
best  dressing  is  weak  boracic  ointment ;  the  protective  and  boracic  lint 
tend  to  increase  the  oedema  by  confining  the  moisture.  As  soon  as 
any  of  these  ulcers  get  into  a  healthy  condition,  skin-grafting  should  be 
employed. 

(4)  Irritable  Ulcer. — The  intense  pain  associated  with  this  form  of  ulcer 
is  best  met  by  cauterising  the  ulcer  thoroughly  by  means  of  nitrate  of  silver, 
so  as  to  completely  destroy  the  sensitive  terminations  of  the  nerve.     Treat- 
ment on  the  principles  recommended  for  a  simple  ulcer  should  be  subse- 
quently carried  out.     Where  quite  small,  complete  excision  with  immediate 
skin-grafting  is  the  best  treatment  for  these  affections. 

(5)  The   Phagedenic    Ulcer. — This  ulcer  requires  energetic   treatment   in 
order  to  destroy  the  infected  tissues,  and  this  may  be  done,  after  the  slough 
has  been  scraped  away  by  a  sharp  spoon  or  clipped  off  by  scissors,  either 
by  means  of  the  actual  cautery  (see  p.   19),  by  potassa  fusa  (see  p.  20),  or 
by  nitric  acid.     Where  nitric  acid  is  used  its  action  should  be  neutralized, 
after  the  lapse  of  a  few  minutes,  by  pouring  on  the  wound  a  strong  solution 
of  ordinary  washing  soda ;  this  should  be  done  until  effervescence,  from  the 
liberation  of  carbonic  acid  gas,  ceases.     Of  these  the  actual  cautery  is  the 
best.     It  should  be  heated  to  white  heat,  and  the  parts  thoroughly  destroyed 
by  it.     By  means  of  the  cautery,  (Paquelin's  cautery  will  also  answer  the 
purpose,)  one  can  gauge  the  amount  of  destruction  done  ;   whereas  caustic 
potash   generally   destroys    more    of   the    tissue    than    is    really   necessary ; 
whilst  the  coagulation  of  the  albumen  caused  by  nitric  acid  interferes  with 
its  action,  so  that,  as  a  rule,  it  does  not  extend  sufficiently  deep.     Sub- 
sequent to  the  application  of  the  escharotic,  undiluted  carbolic  acid  should 
be  sponged  over  the  surface,  and  a  dressing  of  strong  carbolic  oil  (i  to  5), 
as  directed  on  page  47,  should  be  applied.      Here  the  first  object  is  not 
to  obtain  healing,  but  to  eradicate  a  most  dangerous  bacterial  poison,  and 
one  which  spreads  with  intense  rapidity. 

(6)  Varicose  Ulcer  must  be  treated  on  the  lines  already  mentioned  (see 
p.  43),   namely,  by  rest  in  the  elevated  position,  disinfection  of  the  sore, 
the  application  of  protective  and  boracic  lint  dressing,  or  boracic  ointment, 
and  by  subsequent  skin-grafting.     But  the  patient  should  not  be  allowed  to 
go  about  again  till  the  varicose  veins  have  themselves  been  treated.     As 
long  as  the  limb  is  elevated  the  presence  of  varicose  veins  does  not  delay 
the  healing,  but  directly  the  patient  begins  to  walk  about  they  favour  in  a 
very  marked  degree  the  subsequent  breaking  down  of  the  ulcer.     As,  how- 
ever,  under   proper   conditions,  the   varicose   veins   do   not    interfere   with 


60  ULCERATION. 

the  healing  of  the  wound,  it  is  well  to  defer  the  operation  till  the  ulcer 
has  closed,  so  as  to  avoid  any  risk  whatever  of  sepsis  occurring  in  connec- 
tion with  the  operation  on  the  veins.  The  treatment  of  varicose  veins  will 
subsequently  be  referred  to  ;  it  consists  essentially  in  the  removal  of  portions 
of  the  prominent  veins,  especially  the  points  of  junction  of  several  of  their 
branches. 

(7)  Callous   Ulcer. — Here  the  obstacle  to  healing  is  the  callous  condi- 
tion of  the  surrounding  parts,  and  hence  our  first  effort  must  be  directed 
to  getting  rid  of  this  condition.     As  a  matter  of  fact,  if  the  limb  is  put  at 
rest,  the  leg  elevated,  and  the  sore  rendered  aseptic,  this  callous  condition 
will  subside  comparatively  quickly,  and  in  the  course  of  two  or  three  weeks 
the  sore  will   present   a   healthy  appearance  and  the  healing  process  will 
begin.     Where  it  is  desirable  to  expedite  matters,  or  where  the  thickening 
of  the  tissues  does  not  disappear  as  quickly  as  usual,  other  plans,  which 
have  been  referred  to  on  page  45,  may  be  employed,  and  of  these  the  best 
is  the  application  of  a  blister,  provided  always  that  the  kidneys  are  in  a 
healthy  condition.     The  callous  edges  having  been  got  rid  of,  and  the  sore 
having  assumed  a  healthy  condition,  skin-grafting  should  be  employed  in  the 
manner  already  described  (see  p.  50) ;  and  should  varicose  veins  be  present, 
they  should  be  operated  on   after  the  wound  has  healed,  but  before  the 
patient   is   allowed   to    walk   about.      For   the   "  ambulatory "   treatment   of 
callous  ulcer,  see  page  56. 

(8)  Pressure    Ulcer. — A    pressure    ulcer    occurring    in    the    centre   of  a 
callosity  is  sometimes  very  obstinate  in  healing,  and  the  best  treatment  is 
to   cut  away  the  callosity  which   surrounds   the   ulcer,  and  to  scrape  the 
surface  of  the  latter.     In  this  way  a  shallow  healthy  sore  is  left,  which  heals 
comparatively  quickly.     Of  course  the  sore  should  be  disinfected,  and  the 
limb    elevated    and    kept   at   rest   in    the   usual    manner.      Where    a    pres- 
sure ulcer  occurs  in  the  foot,  it  is   perhaps  well  to  skin-graft  it,  in  order 
to  avoid  the  thin  scar  which  results  from  the  natural   process  of  healing, 
and  which  is  very  apt  to  remain  tender  or  break  down  subsequently  ;  and 
when  the  patient  first  begins  to  walk  about,  the  boot  should  be  excavated 
at  the  part  corresponding  to  the  scar,  so  that  pressure  does  not  tell,  for  a 
time  at  any  rate,  on  the  seat  of  the  previous  ulcer. 

(9)  Paralytic   Ulcer. — Here  it  is  often  very  difficult   to   obtain    healing, 
and  stimulant    applications    should   be    employed.     In   the   early  stage   the 
cyanide  gauze  should  be  applied  directly  to  the  raw  surface,  after  the  ulcer 
has  been  disinfected.      The  gauze  is  very  useful  as  a  means  of  inducing 
granulation.     After  granulation  has  occurred  the  best  dressing  is  perhaps 
boracic  lint  soaked  in  balsam  of  Peru.     This  dressing  is  antiseptic,  and  at 
the  same  time  possesses  a  markedly  stimulant  action ;  it  should  be  changed 
daily.      When    healing    is    well    in    progress    the    quarter-strength    boracic 
ointment   (see   p.  48)  should  be   substituted.      The   position   of  the   limb, 
test,  the  administration  of  nourishing  diet,  etc.,  must  of  course  be  attended 
to.     Besides   this   the   application    of  spirits   of  wine  to   the   parts   around 


TREATMENT  OF  INDIVIDUAL  ULCERS.  6l 

and  the  use  of  massage  (see  p.  22)  and  electricity  to  the  whole  limb 
should  be  had  recourse  to  with  the  view  of  improving  the  nutrition  and 
increasing  the  circulation.  The  electric  current  may  be  employed  in 
one  of  two  ways.  The  first  and  simplest  plan  consists  in  covering  the 
whole  of  the  ulcerated  area  with  a  layer  of  gauze  or  absorbent  wool, 
thoroughly  wetted  with  salt  solution  or  boracic  lotion,  and  applying  to  this 
the  negative  pole  of  an  induction  coil,  the  positive  pole  being  applied  to 
the  spinal  column.  A  gentle  current  of  about  5  milliamperes  should  be 
used  at  first;  if  this  causes  pain  it  must  be  diminished.  The  apparatus 
should  be  so  arranged  that  the  circuit  can  be  opened  and  closed  about 
30  times  per  minute.  The  sittings  should  occupy  from  10  to  15 
minutes  and  may  be  made  daily.  The  strength  of  the  current  may  be 
cautiously  increased  up  to  10  or  more  milliamperes,  but  it  should  never 
be  strong  enough  to  cause  pain.  The  other  method  is  to  immerse  the 
affected  limb  in  a  small  electrical  bath.  This  may  be  improvised  by  using 
a  china  basin  or  wooden  tub  or  trough  of  suitable  size,  which  is  filled  with 
salt  solution  and  in  which  the  affected  part  is  immersed.  The  electrodes, 
which  should  be  in  the  form  of  flat  copper  plates  connected  with  the 
poles  of  an  induction  coil,  are  placed  on  either  side  of  the  limb,  the  negative 
being  in  direct  contact  with  the  ulcer.  A  current  sufficiently  weak  for  the 
patient  to  bear  without  discomfort  must  be  employed.  This  method  is 
more  cumbrous  than  the  first  and  offers  no  advantages  over  it. 

10.  The  Perforating  Ulcer  of  the  Foot  is  often  obstinate  under  treatment. 
The  limb  may  be  placed  on  a  splint,  at  rest  in  the  elevated  position  for  a 
long  time,  without  the  slightest  attempt  at  healing  occurring.  One  reason 
for  this  is  no  doubt  the  tendency  of  the  epithelium  to  fill  up  the  cavity 
and  decompose  there,  or  else  to  spread  down  the  edges  of  the  ulcer. 
The  most  satisfactory  plan  in  these  cases  is  to  excise  the  edges  and  sides 
of  the  ulcer,  cut  away  the  whole  of  the  callosity  around,  scrape  out  the 
bottom  of  the  ulcer  until  sound  tissue  is  reached  and  then  disinfect  the 
whole  surface  with  undiluted  carbolic  acid  (see  p.  46)  and  dress  it  anti- 
septically.  Healing  will  not  begin  until  the  cavity  of  the  ulcer  has  filled 
up  with  granulations.  Therefore  it  is  well  to  promote  granulation  by 
stuffing  the  cavity  lightly  with  cyanide  gauze  which  by  its  irritation 
greatly  favours  this  occurrence.  The  gauze  should  be  sprinkled  over  with 
iodoform  and  changed  daily.  When  the  granulations  have  grown  nearly  up 
to  the  level  of  the  surrounding  surface  some  non-irritating  dressing  such 
as  the  quarter-strength  boracic  ointment  (see  p.  48)  may  be  substituted 
for  it.  In  cases  where  the  ulcer  is  extensive,  skin-grafting  may  with 
advantage  be  employed. 

(n)  Lastly,  with  regard  to  the  ulcers  which  are  dependent  on  con- 
stitutional conditions,  more  especially  diabetic  ulcers,  the  local  treatment 
must  be  carried  out  on  the  same  principles,  namely,  disinfection,  position, 
and  careful  dressing.  Of  dressings,  boracic  fomentations  are  the  best  at 
first,  but  these  ulcers  will  not  do  well  unless  something  is  done  to 


62  ULCERATION. 

improve  the  constitutional  condition.  In  the  case  of  diabetes,  the  patient 
must  be  put  upon  the  anti-diabetic  diet  and  codeine  :  these  will  be 
referred  to  more  in  detail  in  speaking  of  diabetic  gangrene  (see  p.  76). 
In  a  diabetic  patient  operations  are  not  satisfactory,  and  this  is  the  one 
form  of  ulcer  in  which  skin-grafting  cannot  be  recommended.  The  ulcer 
should  be  simply  allowed  to  heal  if  it  will,  and  should  be  supported 
afterwards  by  Unna's  bandage,  etc.,  with  the  object  of  preventing  a 
recurrence. 


CHAPTER    IV. 

GANGRENE. 

DEFINITION. — By  gangrene  is  meant  death  of  macroscopic  portions 
of  the  tissues,  and  the  term  is  usually  employed  only  when  the  portion 
which  dies  is  extensive,  more  especially  where  the  whole  or  part  of  an 
extremity  is  affected.  If  the  portion  of  gangrenous  tissue  be  small,  the 
dead  part  is  termed  a  slough,  and  the  process  is  spoken  of  as  sloughing. 

CLASSIFICATION. — In  speaking  of  gangrene  two  classifications  are 
employed,  the  one  a  clinical  classification  into  dry  and  moist  gangrene, 
the  other  an  etiological  one  into  direct,  indirect,  and  specific  gangrene. 
The  use  of  the  latter  classification  makes  the  whole  subject  of  treatment 
more  intelligible. 

SYMPTOMS. — It  will  save  repetition  if  we  speak  first  of  the  terms 
dry  and  moist  gangrene.  Dry  Gangrene  is  the  form  met  with  when 
the  gangrene  occurs  so  slowly  that  the  fluids  of  the  part  have  time  to 
dry  up.  Under  these  circumstances  the  dead  tissues  do  not  form  proper 
pabulum  for  the  ordinary  putrefactive  bacteria,  and  therefore  the  usual 
signs  of  putrefaction  are  wanting.  The  part  usually  has  a  mouldy  rather 
than  a  foul  odour,  and  there  is  not  the  same  amount  of  septic  absorption 
as  in  the  moist  form.  The  patient  is  at  first  comparatively  or  altogether 
free  from  fever  and  symptoms  of  septic  poisoning,  and  there  is  less 
inflammation  in  the  neighbourhood  of  the  dead  part  than  is  the  case  in 
the  moist  variety.  The  gangrenous  part  is  black,  shrivelled  up,  greasy, 
and  semi-transparent  from  the  breaking  down  of  the  fat,  so  that  the 
tendons  and  bones  can  be  seen  through  the  skin.  At  the  junction  of  the 
dead  with  the  living  part  there  is  a  faint  red  blush.  In  dry  gangrene, 
as  a  rule,  the  line  of  demarcation  is  imperfect,  and  after  a  time  fresh 
gangrene  may  appear  above  it.  The  chief  symptom  is  pain. 

Moist  Gangrene,  on  the  other  hand,  is  characterized  by  the  rapid 
putrefaction  of  the  dead  part,  and  the  patient  soon  shows  signs  of  septic 
absorption.  The  gangrenous  part  is  generally  reddish  at  first,  and  ulti- 
mately becomes  black ;  bullae  containing  dark  foul  fluid  form  over  it,  and 
it  crepitates  on  pressure  from  the  presence  of  gas.  The  soft  parts  become 
liquefied  and  separate  from  the  bone  as  a  dark  slimy  foul-smelling  mass. 
Around  the  edge  of  the  gangrene  there  is  marked  redness  and  more 


64  GANGRENE. 

or  less  rapid  formation  of  a  definite  line  of  demarcation.  Without  going 
fully  into  the  symptoms,  it  is  self-evident  that  dry  gangrene  is  much  less 
unfavourable  to  the  patient  than  the  moist  form. 

TREATMENT — (a)  Local. — The  treatment  of  gangrene  depends,  to 
a  great  extent,  on  the  cause  of  the  particular  form,  but  it  will  be  of 
advantage  to  refer  here  to  one  or  two  general  principles.  It  is  evident, 
from  what  has  been  said  as  to  the  difference  in  the  symptoms  in  moist  and 
dry  gangrene,  that  the  most  important  point  in  the  treatment,  if  the 
gangrenous  part  be  not  removed,  is  to  prevent  the  septic  decomposition 
which  will  otherwise  take  place — in  other  words,  to  favour  the  production 
of  the  dry  form.  Hence,  if  it  be  suspected  that  gangrene  is  about  to  take 
place,  as,  for  example,  where  the  circulation  in  a  part  does  not  recover 
in  reasonable  time  after  embolism  or  ligature  of  an  artery,  the  skin  should 
be  disinfected  as  thoroughly  as  possible.  The  limb  is  shaved  and  rubbed 
with  turpentine  so  as  to  remove  the  grease,  and  then  washed  with  soap  and 
strong  mixture  (see  p.  46).  By  means  of  a  nail  brush  the  part  is 
thoroughly  scrubbed  for  a  considerable  time  with  the  strong  disinfecting 
solution,  and  especial  attention  should  be  paid  to  the  nails,  which  should 
be  cut  short;  the  folds  of  skin  under  and  about  them  should  be  scrubbed 
with  extreme  care.  Having  thoroughly  carried  out  the  disinfection,  the 
next  procedure  is  to  apply  an  antiseptic  dressing  designed  to  prevent 
•decomposition  and  at  the  same  time  to  allow  drying  of  the  part.  The 
best  is  that  usually  employed  for  wounds,  namely,  a  large  mass  of  cyanide 
gauze  soaked  in  a  weak  antiseptic  solution,  such  as  a  1-4000  sublimate 
solution,  outside  which  is  applied  a  thick  layer  of  salicylic  or,  better, 
freshly  sterilized  wool,  taken  direct  from  the  sterilizer  and  on  which  no 
dust  has  settled.  It  should  be  borne  in  mind  that  the  organisms  in  dust 
have  to  be  guarded  against,  as  well  as  the  pyogenic  and  other  pathogenic 
organisms.  This  dressing  permits  drying,  and  it  should  not  be  disturbed 
unless  it  is  wished  to  ascertain  whether  death  has  occurred,  or  unless 
discharge  comes  through.  Above  all  things,  the  use  of  ointments  should 
be  avoided,  because  they  prevent  the  evaporation  of  the  fluid,  and  so 
keep  the  gangrenous  part  moist.  The  limb  should  be  placed  on  a  water 
pillow  and  slightly  elevated.  Other  points  in  the  treatment  of  gangrene, 
especially  the  question  of  amputation,  will  be  considered  in  connection 
with  the  particular  forms  of  gangrene. 

(b)  General. — The  general  treatment  will  consist  in  the  administration 
of  strong  and  easily  digested  food,  such  as  various  extracts  of  beef,  bovril, 
Valentine's  meat  juice,  lean  underdone  meat,  chicken,  game,  fish,  etc. 
Stimulants  are  usually  necessary ;  the  best  is  brandy,  or,  if  there  be  no 
diabetes,  champagne.  Besides  these,  drugs,  more  especially  opium,  must  be 
employed  to  relieve  the  pain,  and  the  excretions,  in  particular  the  free 
evacuation  of  the  bowels,  must  be  attended  to.  The  urine  should  be 
carefully  examined  for  sugar  or  albumen,  and  if  either  be  found  the  necessary 
diet  and  treatment  must  be  adopted. 


GANGRENE  DUE  TO  CRUSHING.  65 

ETIOLOGICAL  CLASSIFICATION —We  may  now  pass  on  to  the 
consideration  of  the  etiological  classification  of  gangrene,  according  to  which 
there  are  three  great  varieties,  namely,  direct,  indirect,  and  specific  gangrene. 
By  direct  gangrene  is  meant  gangrene  of  a  part  which  has  been  directly 
subjected  to  an  injury,  as,  for  instance,  where  a  cart  wheel  passes  over  the 
foot  and  the  result  is  that  the  foot  dies.  Indirect  gangrene  is  where  the 
gangrene  occurs  at  some  distance  from  the  cause,  as,  for  instance,  where, 
after  ligature  of  the  femoral  artery,  the  foot  becomes  gangrenous ;  and 
specific  gangrene  is  the  variety  due  to  specific  organisms,  for  example, 
phagedena,  acute  traumatic  gangrene,  and  the  like. 

A.  Direct  Gangrene  may  be  due  (i)  to  crushing  of  the  part,  (2)  to 
pressure,  (3)  to  acute  inflammation,  and  (4)  to  the  action  of  heat  or  cold. 

(i)  Gangrene  due  to  Crushing. — The  most  common  cause  of  direct 
gangrene  is  severe  contusion  or  crushing,  as,  for  example,  where  a  limb  has 
been  run  over.  In  some  cases  the  parts  which  are  directly  subjected  to 
injury  may  lose  their  vitality  at  once ;  in  other  cases,  where  septic  inflam- 
mation occurs  subsequently,  tissues  may  die  which  were  not  killed  outright 
by  the  injury  itself.  Further,  we  may  in  these  cases  have  indirect  as  well 
as  direct  gangrene;  for  example,  where  the  wheel  of  a  heavy  cart  passes 
over  the  leg  it  may  rupture  the  blood-vessels  going  to  the  foot,  and  so 
lead  to  gangrene  of  the  toes  and  the  foot  as  well  as  of  the  tissues  at 
the  .site  of  the  injury.  This  form  of  gangrene  is  moist,  and  the  constitu- 
tional symptoms  and  local  appearances  depend  on  whether  or  not  it  has 
been  possible  to  render  the  part  aseptic  immediately  after  the  injury. 

Treatment. — In  this  form  of  gangrene  affecting  the  extremities,  it  is  not 
always  easy  at  first  to  say  whether  the  part  be  killed  or  not;  hence  it  is  well, 
when  the  state  of  the  patient  will  permit,  to  wait  until  it  is  possible  to 
ascertain  the  exact  extent  of  the  injury.  But  at  the  same  time,  while 
waiting,  means  must  be  taken  to  prevent  or  diminish  as  far  as  possible 
the  putrefaction  of  any  portion  which  may  die.  The  parts  should  there- 
fore be  disinfected  thoroughly  in  the  manner  just  described  (see  p.  64),  and 
a  dressing  applied  and  left  on  for  twenty-four  or  forty-eight  hours,  till  it  is 
seen  how  much  tissue  is  going  to  die.  An  additional  advantage  of  delay 
is  that  the  patient  may  recover  from  the  shock  of  the  accident  before  he  is 
subjected  to  the  shock  of  the  amputation ;  one  of  the  great  dangers  of 
primary  amputation  is  the  addition  of  the  shock  of  the  operation  to  the 
shock  caused  by  the  injury. 

The  question  of  amputation  depends  upon  the  amount  of  injury  done. 
In  some  cases  there  is  no  object  in  waiting,  because  it  can  be  seen  at 
once  that  the  injury  is  irreparable.  For  example,  where  not  only  the  skin 
but  also  the  bones,  the  vessels  and  the  nerves  are  destroyed,  there  can 
be  no  question  as  to  the  advisability  of  amputation.  On  the  other  hand, 
if  the  blood-vessels  and  nerves  are  intact,  it  may  still  be  possible  to  save 
the  limb,  even  although  the  bones  be  extensively  crushed,  and  a  large 
area  of  skin  destroyed,  provided  always  that  the  wound  be  rendered 

E 


66  GANGRENE. 

completely  aseptic.  Formerly,  if  the  bones  were  extensively  injured  ampu- 
tation was  performed,  even  although  the  large  vessels  and  nerves  were 
intact,  but  sufficient  experience  has  now  shown  us  that,  in  a  very  large 
number  of  cases,  compound  fractures  can  be  safely  treated  under  antiseptic 
precautions,  without  recourse  to  amputation.  Formerly,  also,  it  was  held 
best  to  amputate  where  large  portions  of  the  skin  were  lost,  even  although 
both  vessels  and  bones  were  intact,  because  violent  inflammation  and  septic 
absorption,  leading  to  a  fatal  result,  often  occurred  :  if  the  patient  survived, 
either  the  wound,  owing  to  the  difficulty  of  contraction,  did  not  heal  at 
all,  or  if  it  did,  the  contraction  was  so  great  as  to  cause  great  deformity, 
and  render  the  extremity  useless.  At  the  present  time,  however,  these 
risks  can  to  a  certain  extent  be  avoided,  and  even  where  extensive 
portions  of  skin  are  lost  amputation  is  not  always  necessary.  In  the 
first  place,  if  the  part  be  disinfected  in  the  manner  just  described  (see 
p.  64),  and  if  asepsis  be  obtained,  it  frequently  happens  that  a  con- 
siderable amount  of  tissue  which  would  otherwise  have  died  retains  its 
vitality.  In  the  second  place,  by  the  use  of  skin-grafting  when  the 
wound  has  begun  to  granulate  (see  p.  50),  the  great  contraction  which 
would  otherwise  result  is  avoided,  while  at  the  same  time  wounds  can 
be  got  to  heal  which  otherwise  would  not  heal  at  all.  In  patients 
who  are  very  old,  or  much  broken  down  in  health,  and  to  whom  a  long 
confinement  to  bed  would  be  very  injurious,  more  particularly  if  they 
are  the  subjects  of  renal  disease,  amputation  is  however  often  the 
safest  procedure.  Where  diabetes  is  present  the  cases  in  which  an 
attempt  should  be  made  to  save  the  limb  are  comparatively  few. 

(2)  Gangrene  due  to  Pressure. — Another  cause  of  direct  gangrene 
is  continued  pressure,  and  it  is  very  important  to  remember  this  when 
a  patient  has  to  be  kept  in  one  position  for  a  long  time.  Under  such 
circumstances,  the  parts  subjected  to  pressure  are  very  apt  to  die,  and 
this  is  more  especially  the  case  with  soft  parts  over  bony  prominences,  such 
as  the  sacrum,  or  those  subjected  to  pressure  against  the  edge  of  a  splint. 
In  other  words,  we  have  to  do  here  with  the  condition  known  as  bed-sore. 
The  gangrene  in  these  cases  is  moist. 

The  treatment  of  bed-sore  resolves  itself  into  (a)  prophylaxis,  (£)  treat- 
ment where  bed-sore  is  threatened,  and  (c)  where  it  is  actually  present. 

(a)  Prophylaxis. — The  essential  points  in  the  prophylactic  treatment  are 
in  the  first  place  to  avoid  continuous  pressure,  or  so  to  vary  or  diffuse  it 
that  it  shall  not  tell  too  long  or  too  injuriously  on  one  part,  and,  in  the 
second  place,  to  keep  the  skin  dry.  The  first  indication  is  carried  out  by 
frequently  altering  the  position  of  the  patient  or  the  part,  or  by  so  arranging 
matters  that  the  pressure  shall  not  tell  on  any  bony  prominence.  For 
instance,  the  patient  may  lie  on  a  ring  pillow,  the  opening  in  the  pillow 
being  opposite  the  part  where  pressure  is  to  be  avoided. 

Another  and  in  most  cases  the  best  way  is  to  place  the  patient  on  a 
water-pillow  or  a  water-bed,  so  that  the  pressure  does  not  remain  localized 


BED-SORE.  67 

to  any  one  point,  but  is  distributed  over  a  considerable  area.  In  using  a 
water-pillow  care  must  be  taken  that  the  proper  quantity  of  water  is 
introduced  into  it;  if  too  much  be  present  the  pillow  becomes  hard  and 
convex,  and  does  not  apply  itself  equably  to  the  skin,  so  that  as  much 
pressure  is  exerted  upon  the  part  as  if  there  were  no  water-pillow  at  all, 
On  the  other  hand,  if  there  beftoo  little  water  the  patient  is  not  properly 
supported,  and  the  part  comes  into  contact  with  the  bed.  Just  sufficient 
water  should  be  put  in  to  keep  the  patient  floating,  and  a  good  method 
of  testing  this  is  to  bear  one's  whole  weight  on  the  pillow  by  pressing  the 
two  spread-out  hands  in  the  centre ;  if  they  just  touch  the  other  side  of 
the  water-pillow  the  patient's  body  will  float  when  laid  upon  it.  The 
water  in  the  pillow  should  be  tepid  when  introduced,  and  it  ought  to  be 
changed  every  three  or  four  days,  otherwise  it  is  apt  to  become  foul.  A 
large  water-pillow  must  of  course  be  filled  upon  the  bed.  The  pillow  is 
covered  by  a  drawsheet,  and  great  care  should  be  taken  that  this  is  quite 
smooth  and  not  wrinkled. 

A  second  point  in  the  avoidance  of  bed-sore  is  to  see  that  the  parts 
most  exposed  to  pressure  are  kept  thoroughly  dry.  The  patient  should 
be  turned  over  twice  a  day,  and  the  sacrum,  or  any  other  region  sub- 
jected to  pressure,  should  be  carefully  washed  and  thoroughly  dried, 
and  not  only  dried,  but  rubbed  gently  with  a  soft  towel  so  as  to  improve 
the  circulation  and  the  nutrition  of  the  tissues.  It  is  then  dusted  over 
with  powdered  boracic  acid. 

(ft)  Where  a  bed-sore  is  threatening,  that  is  to  say,  where  the  skin  is 
becoming  red,  the  same  measures  should  be  continued,  but  it  is  well  to 
relieve  the  pressure  entirely  by  placing  a  ring  pillow  around  the  part  on 
the  surface  of  the  water-bed.  In  addition  to  gently  rubbing  the  part  with 
a  soft  towel,  the  circulation  should  be  further  promoted  and  the  epidermis 
hardened  by  the  application  of  some  stimulating  fluid,  such  as  spirits  of 
wine  or  whisky.  The  spirits  of  wine  is  allowed  to  dry  on  the  skin,  which 
is  then  rubbed,  and  subsequently  dusted  with  powdered  boracic  acid.  At 
a  later  period,  when  the  skin  is  becoming  raw,  lint  spread  with  equal  parts 
of  balsam  of  Peru  and  resin  ointment  is  a  very  good  application;  it  should 
be  renewed  night  and  morning,  after  the  part  has  been  washed,  dried,  and 
rubbed  with  alcohol. 

(c)  When  a  bed-sore  has  formed,  the  slough,  and  subsequently  the  sore, 
must  be  kept  as  aseptic  as  possible.  Where  the  patient  is  lying  on  the 
part  it  is  impossible  to  carry  out  one  of  the  chief  principles  in  the  treat- 
ment of  gangrene,  namely,  to  favour  the  drying  of  the  slough  ;  and  that 
being  the  case,  there  is  no  objection  to  the  use  of  antiseptic  ointments, 
which  is  after  all  one  of  the  most  valuable  methods  of  keeping  the 
affected  area  aseptic.  The  best  is  the  full-strength  boracic  or  eucalyptus 
ointment,  changed,  when  the  slough  has  separated,  for  the  quarter-strength 
boracic.  The  balsam  of  Peru,  either  alone  or  mixed  with  white  of  egg 
in  equal  proportions,  is  also  a  very  good  dressing.  As  soon  as  possible 


68  GANGRENE. 

the  patient  should  be  made  to  lie  on  the  side,  when  the  sore  will  usually 
begin  to  heal,  unless  the  general  condition  be  extremely  weak.  At  the 
same  time,  the  general  nutrition  of  the  patient  should  be  attended  to  by 
the  administration  of  light  and  easily  digested  food  and  stimulants  (see 
p.  64). 

(3)  Another  cause  of  direct  gangrene  is  acute  inflammation.     Where 
inflammation  occurs  in  dense  tissues,  and  especially  where  it  ends  in  sup- 
puration, the  stasis  and  the  pressure  of  the  exudation  on  the  blood-vessels 
may  lead  to  death  of  the  tissues  from  insufficient  blood  supply.     The  best 
examples   of  this  are  acute  necrosis  following  acute  suppurative  periostitis 
and  osteomyelitis,  and    the   sloughs  which  occur  in  the   skin    in  boils  and 
carbuncles.     These  cases  will  be  dealt  with  under  their  respective  headings  ; 
we  need  only  say  here  that  early  free  incisions  are  called  for. 

(4)  Lastly,  we  have  direct  gangrene  resulting  from   the  action  of  heat 
or  cold,  but  the  treatment  of  burns  and  scalds  and  frostbite  will  be  better 
dealt  with  after  discussing  the  treatment  of  wounds  (see   Chap.  IX.),  and 
we  may  therefore  defer  their  consideration  for  the  present. 

B.  Indirect  Gangrene.  —  By  indirect  gangrene  is  meant  death  of 
tissues  where  the  causal  agent  does  not  act  directly  on  the  part  which 
dies.  There  are  four  groups  of  indirect  gangrene:  (i)  gangrene  due  to 
gradual  diminution  in  the  calibre  of  the  blood-vessels ;  (2)  gangrene  due 
to  the  sudden  obstruction  of  the  blood-vessels;  (3)  gangrene  due  to 
imperfect  innervation ;  and  (4)  gangrene  due  to  general  causes  such  as 
diabetes,  acute  fevers,  the  use  of  ergot,  etc. 

( i )  Gangrene  due  to  the  gradual  diminution  in  the  calibre  of 
the  blood-vessels.  Dry  or  senile  gangrene  is  the  typical  example  of 
this  form.  The  changes  leading  to  senile  gangrene  affect  the  arteries,  and 
are  in  part  gradual  diminution  in  the  calibre  of  the  blood-vessels,  and  in 
part  rigidity  of  their  walls  so  that  they  do  not  dilate  and  contract  in 
conformity  with  the  needs  of  the  tissues.  Anything  which  leads  to  endar- 
teritis  will  favour  the  production  of  this  form  ;  for  example,  alcoholism  is 
a  very  potent  cause  of  endarteritis,  as  are  also  diabetes  and  syphilis,  and 
these  are  among  the  chief  causes  of  senile  gangrene.  Another  very  common 
cause  is  atheroma,  which  is  a  chronic  inflammation  of  the  deeper  part  of 
the  internal  coat  of  the  artery,  leading  to  irregular  thickening  and  rigidity, 
diminution  in  its  calibre,  and  even  in  some  cases  going  on  to  calcification 
of  the  middle  coat.  In  atheroma  and  endarteritis  a  further  cause  of  gan- 
grene is  the  great  tendency  to  the  occurrence  of  thrombosis  in  the  affected 
vessels,  thus  leading  to  complete  blocking  of  their  lumen. 

It  is  evident  that  certain  symptoms,  due  to  imperfect  blood  supply, 
will  in  most  cases  precede  the  occurrence  of  the  gangrene.  Thus,  one 
of  the  chief  complaints  of  the  patient,  even  long  before  the  gangrene 
occurs,  is  great  coldness  and  perverted  sensation  in  the  feet.  He  suffers 
much  from  tingling,  he  does  not  feel  the  ground  properly  when  he  walks, 
he  feels,  in  fact,  as  if  there  were  something  soft  between  his  feet  and 


SENILE   GANGRENE.  69 

the  ground.  The  further  history  of  the  case  is  that  after  these  symptoms 
have  lasted  a  varying  length  of  time  something  occurs  which  sets  up  a 
little  inflammation  about  the  foot.  Possibly  a  blister  forms  as  the  result 
of  tight  boots,  or  a  corn  suppurates,  or  in  paring  a  corn  the  tissues  are 
injured  :  some  such  trivial  cause  usually  leads  to  inflammation,  with  the 
result  that  the  tissues  being  very  weak,  gangrene  takes  place,  whereas  in 
healthy  tissues  the  inflammation  would  have  passed  off  without  any  trouble. 
When  gangrene  has  started  it  goes  on  very  slowly,  and  it  may  be  weeks 
or  even  months  before  more  than  the  toes  die.  The  appearances  are 
those  typical  of  dry  gangrene  (see  p.  63). 

General  condition  of  Patient. — The  patient  for  some  time  remains  in 
a  good  state  of  health,  and  his  chief  complaint  is  the  pain  which  he  suffers, 
and  which  may  be  intense.  As  the  result  of  the  severe  pain,  he  becomes 
sleepless,  and  after  a  short  time  his  pulse  loses  its  fulness,  and  he  gets  very 
restless.  If  the  disease  be  allowed  to  run  its  course,  the  patient  will  in 
most  cases  die  of  it,  being  worn  out  by  the  pain  and  want  of  sleep,  or  by 
some  septic  disease  which  has  its  origin  at  the  line  of  demarcation.  In 
some  cases,  however,  recovery  takes  place,  the  line  of  demarcation  forming 
very  slowly,  and  the  dead  part  being  gradually  cast  off. 

Treatment. — In  describing  the  treatment  of  this  form  of  gangrene,  we 
must  consider  the  prophylactic  treatment  as  well  as  that  called  for  when 
the  gangrene  has  actually  set  in.  First,  as  regards  the  prophylaxis. 
When  an  elderly  patient  comes  complaining  of  the  symptoms  which  have 
been  mentioned  as  indicating  imperfect  circulation  in  the  foot,  and  where 
on  examination  of  the  vessels  it  is  found  that  they  are  thickened,  or 
perhaps  devoid  of  pulsation,  great  pains  should  be  taken  to  explain  the 
danger,  and  to  point  out  how  slight  are  the  injuries  which  may  precipitate 
the  onset  of  the  gangrene.  He  should  be  prohibited  from  wearing  tight 
boots,  and  should  be  specially  cautioned  to  avoid  any  injury  to  the  foot, 
however  trivial  it  may  appear.  Above  all  he  should  be  warned  not  to 
place  his  feet  in  hot  baths  or  before  a  very  warm  fire,  for  in  the  imperfect 
state  of  the  circulation  the  heat  is  apt  to  bring  on  gangrene.  If  his  feet 
are  very  cold,  he  may  place  them  in  a  bath  of  from  80°  to  85°  F.,  tested 
by  a  thermometer,  and  he  may  then  have  them  gently  rubbed  with  a  soft 
towel.  He  should  wear  warm  stockings,  and  warm,  light,  fur-lined  shoes 
or  slippers.  In  bed  he  should  wear  thick  bed-socks,  and  the  bed  may  be 
warmed  with  hot  bottles,  which  however  should  either  be  taken  away 
before  he  gets  into  bed,  or  removed  to  such  a  distance  that  his  feet 
cannot  reach  them,  and  in  all  cases  the  bottles  should  be  wrapped  up  in 
thick  flannel.  At  the  same  time  the  diet  must  be  nourishing,  and  plenty 
of  fresh  air  and  light  exercise  should  be  insisted  upon. 

Directly  gangrene  has  actually  occurred,  or  as  soon  as  it  is  evident  that 
it  is  inevitable,  the  first  essential  in  the  treatment  is  to  disinfect  the  part 
thoroughly  in  the  manner  already  described  (see  p.  64),  and  to  favour 
evaporation  of  fluid  from  the  tissues.  Above  all  things,  ointments,  carbolic 


70  GANGRENE. 

oil,  and  other  greasy  dressings  should  be  entirely  avoided,  and  only  those 
employed  which  permit  drying  of  the  part.  The  cyanide  gauze  next  the 
skin,  with  some  sterilized  or  salicylic  wool  outside,  probably  forms  the  best 
dressing.  The  patient  should  remain  in  a  recumbent  position,  with  the  foot 
kept  warm  and  slightly  elevated.  The  strength  must  be  supported  by 
generous  diet  and  fresh  air,  obtained  if  possible  by  wheeling  the  patient  out 
in  a  suitable  reclining  chair  every  day.  The  heart's  action  must  be  assisted 
as  far  as  possible,  and  for  this  purpose  the  use  of  Tinct  Nucis  Vomicse 
in  5-minim  doses,  combined  with  5  minims  of  the  Tinct.  Digitalis,  three 
times  a  day,  is  of  great  use.  Steps  should  also  be  taken  to  relieve  the 
pain,  more  especially  by  the  free  administration  of  opium.  Opium  has  a 
very  beneficial  effect  in  many  cases  of  senile  gangrene,  even  where  there 
is  no  diabetes.  It  probably  acts  mainly  by  relieving  the  pain,  and  thus 
enabling  the  patient  to  get  sound  rest  and  sleep  ;  but  some  authorities 
seem  to  consider  that  opium  has  a  specific  action  in  gangrene.  It  should 
be  given  four  times  a  day,  beginning  with  10  to  12  minims  of  laudanum, 
and  gradually  increasing  the  dose.  At  the  same  time  the  bowels  must  be 
kept  freely  open,  preferably  by  the  use  of  mineral  waters,  such  as  a  wine- 
glassful  of  Hunyadi  Janos,  or  half  a  tumblerful  of  Friedrichshall  in  warm 
water  every  morning  on  rising,  or  with  seidlitz  powders  and  enemata. 
Stimulants  will  probably  be  required,  certainly  at  a  later  period,  and  whisky 
and  brandy,  in  amounts  from  3  to  6  ounces  daily,  are  the  best. 

At  an  early  period  the  question  of  amputation  must  be  carefully  con- 
sidered. The  old  rule  was  that  amputation  should  never  be  performed  in 
senile  gangrene,  but  that  the  part  should  be  allowed  to  drop  off,  the 
utmost  surgical  interference  allowed  being  to  snip  through  dead  tendons  or 
bones,  and  on  no  account  to  interfere  with  the  living  tissues.  The  reason 
for  this  was  that  before  the  antiseptic  era  acute  inflammation  almost  always 
followed  amputation,  and  when  inflammation  occurs  in  these  weak  tissues 
it  is  very  likely  indeed  to  lead  to  sloughing  of  the  flaps  and  more  rapid 
progress  of  the  gangrene,  which  then  becomes  of  the  moist  variety.  At 
the  present  time  however  we  can  avoid  this  inflammatory  disturbance,  and 
therefore  the  rules  as  regards  amputation  in  senile  gangrene  are  completely 
altered.  It  is  now  not  so  much  a  question  of  recurrence  of  gangrene  in 
the  stump,  as  whether  the  patient  has  sufficient  recuperative  power  to 
recover  from  the  operation.  In  cases  where  the  answer  to  this  question 
is  doubtful,  it  must  be  remembered  that  the  patient  if  left  alone  will  almost 
certainly  die  from  the  senile  gangrene,  and  therefore  that  amputation  offers 
practically  the  only  chance.  By  operating  early,  and  by  amputating  well 
above  the  dead  part,  the  patient's  strength  is  preserved,  he  is  not  worn 
out  by  pain  and  loss  of  sleep,  and  he  is  in  a  much  better  condition  to 
survive  the  operation  than  if  it  were  delayed.  The  only  difficulty  is  that 
it  is  not  always  possible  to  gauge  how  far  the  process  will  extend  ;  as  a 
rule  this  can  be  determined  by  ascertaining  the  point  at  which  pulsation 
in  the  main  vessels  ceases.  In  some  rare  cases  where  the  arterv  can  be  felt 


GANGRENE   FROM   OBSTRUCTION.  71 

beating  strongly  at  the  ankle  joint,  amputation  may  be  performed  there, 
preferably  by  means  of  an  internal  flap.  In  most  cases  the  pulsation  at  the 
ankle  is  very  slight,  if  present  at  all,  and  if  pulsation  cannot  be  felt  there 
the  best  place  for  amputation  is  the  knee  joint.  The  thrombus  which  forms 
in  the  diseased  vessels  when  the  amputation  is  done  through  the  ankle  is 
very  apt  to  extend  upwards  as  far  as  the  knee  and  lead  to  gangrene  of 
the  flaps.  Generally,  therefore,  amputation  through  the  knee  joint  is  more 
suitable. 

(2)  The  second  form  of  indirect  gangrene  is  that  due  to  some  sudden 
obstruction  of  the  blood-vessels.  This  may  be  the  result,  firstly,  of 
pressure  outside  these  structures,  for  example,  after  ligature,  the  applica- 
tion of  tight  bandages,  pressure  from  the  fractured  ends  of  bones,  etc.; 
secondly,  of  rupture  of  their  walls,  as,  for  example,  in  dislocations  or  in 
attempted  reduction  of  dislocations ;  and,  thirdly,  of  blocking  of  their  lumen, 
more  especially  embolism  with  subsequent  thrombosis. 

In  the  first  two  cases  the  vein  may  be  blocked  as  well  as  the  artery, 
and  while  this  makes  no  essential  difference  in  regard  to  treatment,  the 
symptoms  vary  somewhat.  Where  the  obstruction  is  primarily  arterial,  the 
first  thing  that  is  noticed  is  that  the  limb  below  becomes  pallid  from 
absence  of  blood ;  it  then  assumes  a  dark  livid  colour,  and  the  various 
changes  already  described  as  characteristic  of  moist  gangrene  follow.  In 
embolism  there  is,  in  addition  to  the  sudden  whiteness  of  the  limb,  violent 
pain  at  the  point  where  the  embolus  has  been  arrested,  and  this  is  a  very 
valuable  sign  as  showing  where  the  block  has  occurred.  When,  however, 
the  case  afterwards  comes  to  amputation  it  must  not  be  assumed  that  the 
seat  of  pain  is  the  upper  limit  of  the  obstruction,  because,  subsequently  to 
the  embolism,  thrombosis  takes  place  and  may  extend  upwards  for  a  con- 
siderable distance.  If  there  be  venous  as  well  as  arterial  obstruction  at 
the  commencement,  the  part  below  remains  dark  and  becomes  cedematous 
very  quickly. 

In  these  cases  the  treatment  depends  on  the  extent  of  the  gangrene, 
and  the  great  question  for  consideration  is  that  of  amputation.  Before 
deciding  this  point,  sufficient  time  should  be  allowed  to  elapse  to  enable 
the  surgeon  to  see  how  much  of  the  collateral  circulation  will  be  established, 
because  although  at  first  the  part  may  appear  white  and  dead,  a  very  con- 
siderable portion,  or  indeed  the  whole,  may  recover  as  the  result  of  the 
enlargement  of  the  anastomotic  circulation.  While  waiting,  however,  pre- 
cautions must  be  taken  not  to  allow  putrefaction  to  occur,  and  also  to 
permit  drying.  The  skin,  the  toes,  and  the  nails  should  be  at  once  disin- 
fected in  the  manner  already  described  (see  p.  64),  and  the  part  wrapped 
up  in  a  warm  antiseptic  dressing,  permitting  evaporation,  which  should  be 
allowed  to  remain  in  position  for  24  or  48  hours.  If  gangrene  occur  the 
part  very  soon  loses  its  white  colour  and  becomes  dusky  and  remains  cold, 
The  finger  firmly  pressed  into  the  skin  makes  no  difference  to  the  colour ; 
whereas  if  the  circulation  be  maintained,  the  part  pressed  upon  becomes 


72  GANGRENE. 

white,  and  slowly  or  quickly  regains  its  original  appearance  when  the 
pressure  is  discontinued.  When  recovery  takes  place,  it  does  so  within 
the  first  24  hours,  and  when  it  is  certain  how  much  is  going  to  die, 
amputation  should  be  practised  without  further  delay.  There  is  no 
necessity  to  wait  for  the  formation  of  a  line  of  demarcation. 

The  point  at  which  amputation  should  be  done  depends  on  the  anatomy 
of  the  arteries  and  on  the  extent  of  recovery.  It  should,  however,  be 
borne  in  mind  that  the  gangrene  is  generally  less  extensive  in  the  skin 
than  in  the  deeper  parts,  and  therefore,  if  the  flaps  are  cut  close  to  the 
gangrenous  part,  the  incision  will  probably  go  into  dead  tissues  as  it 
is  deepened.  Hence  an  interval  of  at  least  two  or  three  inches  should 
intervene  between  the  line  of  gangrene  and  the  amputation  incision.  In 
many  cases,  however,  amputation  is  done  higher  up  than  this  on  account 
of  the  better  stump  obtained,  or  on  account  of  the  better  anastomotic 
circulation.  Where  there  is  blocking  of  the  veins  as  well  as  of  the  arteries, 
the  chances  of  recovery  are  less,  but  the  rules  of  treatment  are  the  same. 

(3)  The  third  form  of  indirect  gangrene  is  that  dependent  on 
imperfect  innervation  of  the  part.  Where  a  limb  is  paralysed,  the 
nutrition  is  almost  always  deficient,  and  such  limbs  are  especially  liable  to 
the  formation  of  bed-sores  and  gangrene  from  pressure.  In  hemiplegia 
also,  where  the  patient  is  lying  absolutely  still,  he  is  extremely  liable  to 
suffer  from  bed-sores  which  are  worse  on  the  paralysed  side  than  on  the 
sound  one.  Again,  if  extension  be  applied  both  to  a  paralysed  limb  and 
to  a  sound  one,  there  is  much  greater  liability  for  sloughs  to  form  under 
the  extension  plaster  on  the  paralysed  than  upon  the  sound  side. 

The  gangrene  that  occurs  in  these  cases  generally  comes  on  very  quickly. 
It  is  moist,  and  is  often  spoken  of  as  an  acute  bed-sore,  and  it  is  very 
important  to  remember  that  under  such  circumstances  the  greatest  possible 
care  should  be  taken  to  avoid,  as  far  as  possible,  even  the  slightest  pressure. 
The  part  must  be  examined  frequently  to  see  that  its  condition  is  good, 
and  the  limb  should  be  kept  warm  and  slightly  elevated ;  should  sloughing 
occur,  the  case  must  be  treated  like  one  of  bed-sore  (see  p.  67). 

There  is  another  form  of  gangrene  in  connection  with  nervous  derange- 
ments, which  chiefly  comes  under  the  notice  of  the  physician.  This  is 
what  is  termed  symmetrical  gangrene  or  "  Raynaud's  Disease."  This 
form  differs  from  senile  gangrene,  which  it  in  some  respects  resembles, 
in  that  it  is  always  bilateral,  while  senile  gangrene  is  often  one-sided ; 
that  it  more  often  affects  the  fingers  than  the  toes  ;  that  it  is  much  more 
.limited  both  in  extent  (generally  not  reaching  beyond  the  phalanges)  and 
in  depth  (seldom  going  deeper  than  the  skin) ;  and  that  in  "  Raynaud's 
disease "  the  blood-vessels  are  normal,  whereas  in  senile  gangrene  they 
are  thickened  and  hard.  Raynaud's  disease  occurs  especially  in  hysterical 
women  between  eighteen  and  thirty  years  of  age,  and  is  most  probably 
connected  with  uterine  and  menstrual  troubles.  The  attacks  are  often 
brought  on  by  cold,  and  are  most  commonly  met  with  during  the  winter 


RAYNAUD'S    DISEASE.  73 

months.  It  is  supposed  to  be  due  to  spasm  of  the  arterioles  brought 
about  reflexly  by  the  uterine  disorder. 

In  this  affection  certain  phenomena  precede  the  gangrene.  The  ex- 
tremity affected  may  become  quite  white,  and  this  is  evidently  due  to 
contraction  of  the  blood-vessels;  following  this,  or  occurring  without  any 
preliminary  pallor,  the  parts  may  become  of  a  deep  purple  colour,  as  if 
they  had  been  dipped  in  ink.  This  is  evidently  due  to  a  local  venous 
condition  of  the  blood,  from  great  slowing  of  the  circulation.  It  may 
last  for  a  day  or  two,  and  may  or  may  not  lead  to  gangrene.  The  gangrene 
is  of  the  dry  form.  The  darkness  of  the  extremities  just  noted  continues 
for  some  days,  the  pain  and  other  symptoms  increase,  and  small  bullae  may 
possibly  form.  Indeed,  in  the  case  of  the  hand,  it  often  looks  as  if  the 
patient  were  going  to  lose  all  the  fingers.  Ultimately  the  circulation  improves 
very  much,  and  as  a  rule  the  final  result  is  that  only  a  small  piece  of  tissue 
dries  up,  and  ultimately  separates.  The  whole  process  is  very  slow  and 
takes  from  the  commencement  of  the  gangrene  to  the  separation  of  the 
slough  from  twenty  days  to  ten  months.  The  disease  is  very  apt  to  recur. 

Treatment. — In  the  treatment  of  the  local  condition,  the  first  place 
must  be  given  to  the  use  of  stimulation  by  the  electrical  current.  For  this 
purpose  the  constant  current  may  be  used,  and,  as  recommended  by  Dr. 
Barlow,  the  extremity  of  the  affected  limb  should  be  immersed  in  a  large 
basin  containing  salt  and  water.  One  pole  of  the  constant  current  battery 
is  placed  on  the  upper  part  of  the  limb,  whilst  the  other  is  immersed  in 
the  fluid  in  the  basin,  which  is  thus  converted  into  an  electrode.  As 
many  cells  may  be  employed  as  the  patient  can  comfortably  bear,  and  the 
current  is  made  and  broken  at  frequent  intervals,  20  to  30  per  minute, 
so  as  to  get  repeated  moderate  contractions  of  the  muscles  of  the 
limb.  Where  several  of  the  extremities  are  affected,  and  where  it  is 
possible  to  obtain  it,  the  complete  electric  bath  is  best.1  The  bath  itself 
should  be  of  porcelain,  earthenware,  or  wood,  about  5  ft.  6  in.  long,  and 
the  patient  should  be  entirely  immersed  up  to  the  neck  when  lying  in  it. 
The  water  should  be  just  under  100°  F.  The  electrodes  are  large  flat 
copper  plates  fixed  to  the  poles  of  an  induction  coil,  and  should  be  about 
one  foot  square ;  they  are  placed  at  the  head  and  foot  of  the  bath.  The 
shoulders  should  not  touch  the  electrode,  the  feet  may  be  allowed  to  do 
so.  The  current  used  to  begin  with  should  not  exceed  100  milliamperes  : 
after  a  few  baths  it  may  gradually  be  raised  to  150  or  even  200,  if  it  is 
not  painful.  The  current  should  not  be  turned  on  until  the  patient  has 
been  in  the  bath  some  little  time,  and  then  only  very  gradually.  The  bath 
should  last  from  10  to  15  minutes,  and  should  be  repeated  daily  for 
the  first  week ;  then  three  times  a  day  until  about  a  dozen  to  fifteen 
baths  have  been  taken.  This  is  generally  sufficient  to  produce  considerable 

1  For  further  information  concerning  the  use  of  the  electric  bath  the  reader  may  be 
referred  to  Dr.  Lewis  Jones'  excellent  work  on  Medical  Electricity,  2nd  edition  (H.  K. 
Lewis,  London),  to  which  we  are  indebted  for  several  of  the  above  points. 


74  GANGRENE. 

improvement.  Another  mode  of  carrying  out  the  same  treatment  is  to 
carefully  sponge  or  rub  the  limb  over  with  two  sponge  electrodes  held  a 
short  distance  apart,  and  this  is  very  useful  in  reducing  the  pain  that  is 
usually  present.  This  method  of  electrization  may  also  be  employed  even 
where  gangrene  has  actually  occurred,  being  then  of  course  used  for  the 
relief  of  pain  in  the  surrounding  parts. 

The  application  of  the  current  generally  produces  a  somewhat  profuse 
perspiration,  and  is  usually  unaccompanied  by  pain,  and  an  important 
change,  showing  that  the  current  is  doing  good,  is  that  the  hands  frequently 
become  moist,  where  previous  to  its  application  they  were  harsh  and  dry. 
This,  by  Raynaud  himself,  is  considered  one  of  the  most  favourable  elements 
of  prognosis.  He  also  points  out  that  when  this  treatment  has  been  fol- 
lowed for  some  days,  and  improvement  has  distinctly  commenced,  certain 
unpleasant  effects  may  begin  to  manifest  themselves  ;  for  instance,  headache, 
which  is  intensified  by  the  passage  of  the  current,  a  painful  sensation  of 
constriction  in  the  throat  and  general  excitement.  He  states  that,  although 
these  symptoms  are  not  serious,  yet,  should  they  occur,  it  is  proper  to 
diminish  the  number  of  elements  employed. 

Another  very  useful  form  of  treatment,  and  one  that  may  often  be 
advantageously  combined  with  the  use  of  electricity,  is  careful  friction  or 
shampooing.  In  some  cases  this,  however  carefully  it  is  carried  out, 
cannot  be  borne  by  the  patient;  but  it  will  generally  be  found  that,  after 
electricity  has  been  employed  for  some  little  time  in  the  manner  just 
recommended,  the  parts  are  sufficiently  free  from  tenderness  to  bear  careful 
shampooing.  This  should  be  performed  at  first  by  the  hand,  encased  in 
soft  flannel  or  other  suitable  gloves.  After  a  time  friction  by  the  naked 
hand,  anointed  with  some  simple  lubricant,  may  be  substituted.  This 
shampooing  may  also  be  used  with  advantage  for  those  cases  where, 
after  repeated  attacks  of  gangrene,  the  limb  has  become  contracted  and 
anchylosis  has  occurred.  Under  these  circumstances  it  is  of  course  used 
with  a  different  object,  namely,  to  promote  the  nutrition  of  the  muscles 
and  to  facilitate  the  movement  of  the  various  joints.  The  friction  may 
be  carried  out  immediately  after  the  application  of  the  current,  and  may 
be  repeated  more  than  once  during  the  day  if  the  patient  experience 
sensible  relief  from  its  use. 

In  cases  where,  during  the  height  of  the  spasm,  there  is  intense  and 
agonizing  pain,  considerable  relief  seems  to  be  afforded  by  the  application 
of  slight  cold,  and  this  appears  to  be  more  effectual,  at  any  rate  in  abating 
the  pain,  than  the  use  of  hot  fomentations.  For  this  purpose  the  extre- 
mities may  be  covered  loosely  with  a  piece  of  lint,  which  is  dipped  in 
eau  de  Cologne,  or  some  similar  evaporating  spirit,  diluted  with  water.  In 
cases  of  extremely  grave  local  asphyxia,  where  gangrene  was  obviously  im- 
pending, Raynaud  has  made  use  of  the  application  of  leeches  with  apparently 
satisfactory  results.  This  method,  however,  should  not  be  employed  except 
where  the  condition  is  grave,  as  with  it  septic  complications  are  not  at  all 


DIABETIC  GANGRENE. 


75 


unlikely  to  occur.  Wherever  it  appears  imperative  to  relieve  the  local 
congestion,  we  should  prefer  the  use  of  scarifications  (after  the  skin,  etc., 
had  been  rigorously  purified)  followed  by  the  application  of  warm  fomenta- 
tions to  encourage  bleeding. 

General  Treatment. — With  the  local  applications  must  be  combined  the 
administration  of  internal  remedies.  Of  course,  if  there  be  a  marked 
hysterical  condition,  the  patient  may  be  treated  by  massage  and  careful 
feeding,  combined  with  isolation,  as  recommended  by  Weir  Mitchell.  Apart 
from  this,  some  drugs  seem  to  be  of  benefit,  although  there  is  apparently 
none  that  may  be  looked  upon  as  having  any  specific  effect  upon  the 
affection.  Chief  among  these  is  opium,  which  is  useful  in  some  cases. 
Possibly  it  may  to  a  certain  extent  allay  the  spasm,  or  at  any  rate  calm 
the  agonizing  pain  that  is  often  present,  and  in  these  cases  it  may  be 
used  with  considerable  advantage.  The  administration  of  quinine  in  doses 
of  three  or  four  grains  three  times  a  day  is  also  in  some  cases  likely  to 
be  of  use,  both  constitutionally  and  to  the  local  condition.  If  there  be 
pronounced  anaemia,  iron  and  arsenic  may  be  administered,  the  former  as 
Blaud's  preparation  in  capsules  of  five  to  ten  grains  three  times  a  day,  the 
latter  in  the  form  of  Fowler's  solution,  beginning  with  a  dose  of  three 
drops  upon  a  piece  of  sugar  taken  three  times  a  day,  and  gradually 
increased  until  twelve  or  fifteen  minims  are  taken  at  a  time.  Nitrite 
of  amyl  has  been  recommended  from  a  theoretical  consideration  of  its 
action,  but  apparently  without  any  marked  benefit.  Any  uterine  or 
ovarian  trouble  should  be  looked  for,  and  if  present  should  receive  appro- 
priate treatment.  In  addition  to  the  use  of  drugs,  the  patient  should  be 
encouraged  to  take  plenty  of  light  food  and  to  have  sufficient  exercise 
in  the  fresh  air.  The  affected  limb  should  of  course  be  wrapped  up  warmly 
in  flannel  or  lambswool,  and  the  greatest  care  must  be  taken  to  avoid 
exposing  the  extremities  to  sudden  and  extreme  alterations  of  temperature. 
When  sloughing  has  actually  taken  place,  the  treatment  already  described 
for  dry  gangrene  must  be  carried  out,  antiseptic  dressings  being  used,  and 
the  part  allowed  to  dry  up.  In  no  case  is  amputation  necessary. 

(4)  The  fourth  form  of  indirect  gangrene,  due  to  general  causes,  is 
in  some  ways  the  most  important  of  all.  Three  varieties  may  be  mentioned, 
namely,  (a)  gangrene  in  connection  with  diabetes,  (£)  gangrene  after  acute 
fevers,  and  (c}  gangrene  following  the  use  of  ergot. 

(a)  Diabetic  Gangrene. — There  are  two  ways  in  which  diabetes 
may  be  related  to  gangrene.  First,  there  is  the  death  of  the  part  directly 
dependent  upon  the  presence  of  diabetes,  or  the  true  "  diabetic  gangrene  " ; 
second,  there  is  gangrene  from  some  other  cause  taking  place  in  a  patient 
who  is  diabetic.  In  any  case,  the  presence  of  diabetes  affects  the  progress 
of  the  gangrene  in  a  very  marked  degree ;  it  spreads  with  greater  rapidity, 
there  is  more  inflammation  about  the  gangrenous  part,  and  the  gangrene, 
if  dry  at  first,  tends  to  become  moist.  The  patient  generally  dies  either 
of  some  septic  complication,  of  diabetic  coma,  or  of  exhaustion. 


76  GANGRENE. 

Diabetes  leads  to  gangrene,  in  the  first  place,  because  it  gives  rise  to 
endarteritis,  and  consequent  diminution  in  the  calibre  of  the  vessels ;  and 
in  the  second  place,  because  the  tissues  of  the  diabetic  are  weaker  and 
less  able  to  resist  injury  than  healthy  ones ;  they  are  especially  sensitive 
to  the  pyogenic  organisms  which  appear  to  grow  in  them  with  special 
rapidity  and  virulence.  Some  authorities  also  hold  that  the  innervation 
of  the  tissues  is  interfered  with  as  the  result  of  central  nervous  disturbance, 
and  that  they  are  thus  predisposed  to  gangrene. 

Treatment. — Bearing  in  mind  the  great  tendency  to  gangrene,  diabetics 
must  be  specially  warned  to  avoid  any  injury,  however  trivial,  lest  acute 
inflammation,  which  will  probably  become  gangrenous,  should  result ;  more 
especially  they  should  avoid  slight  injuries  to  the  feet,  the  wearing  of  tight 
boots,  etc.  Strict  asepsis  should  be  employed  in  the  case  of  any  wound 
from  which  they  may  suffer,  and  when  gangrene  has  set  in  the  usual 
treatment  should  be  adopted,  namely,  the  disinfection  of  the  limb  and  the 
application  of  an  antiseptic  dressing. 

(i)  General. — The  general  condition  should  be  specially  attended  to 
and  the  patient  placed  on  anti-diabetic  diet,  that  is  to  say,  he  should 
avoid  substances  that  tend  to  the  production  of  sugar,  such  as  sugar  itself, 
all  starchy  foods,  potatoes,  etc.  The  stringency  of  the  diet  must  depend 
on  the  amount  of  sugar  in  the  urine  and  the  condition  of  the  patient ; 
if  he  be  very  weak  it  is  inadvisable  to  put  him  suddenly  on  too  strict 
a  diet.  The  following  dietary,  for  which  we  are  indebted  to  Dr.  Burney 
Yeo,1  will  give  full  details  as  to  the  diet  of  a  diabetic  patient. 

SEEGEN'S   DIETARY. 
Sanctioned. 

IN  ANY  QUANTITY — Flesh  of  all  kinds;  preserved  (smoked)  meats,  ham, 
tongue,  bacon  ;  fish  of  all  kinds ;  oysters  and  shell-fish ;  crabs,  lobsters ; 
animal  jellies;  aspic;  eggs,  caviare,  cream,  butter,  cheese;  spinach, 
cooked  salads,  endive,  cucumber,  green  asparagus,  watercress,  sorrel, 
artichokes,  mushrooms ;  nuts. 

IN  SMALL  QUANTITY — Cauliflower,  carrots,  turnip,  white  cabbage,  green 
beans  ;  berries,  such  as  strawberries,  raspberries,  currants ;  also  oranges 
and  almonds. 

BEVERAGES. 

IN  ANY  QUANTITY — Water,  soda-water ;  tea,  coffee ;  Bordeaux,  Rhine,  and 
Moselle  wines ;  Austrian  and  Hungarian  table  wines.  In  short,  all 
wines  that  are  not  sweet,  and  that  contain  only  a  moderate  amount 
of  alcohol. 

IN  VERY  SMALL  QUANTITIES — Milk,  unsweetened  ;  almond  emulsion  ;  brandy, 
bitter  beer;  lemonade,  unsweetened. 

1  A  Manual  of  Medical  Treatment  or  Clinical  Therapeutics,  Vol.  II.,  p.  554.  Cassell 
&  Co.,  London,  1893. 


DIABETIC   GANGRENE.  77 

Forbidden. 

Farinaceous  foods  of  all  kinds  (bread  only  in  very  small  quantity  according 
to  the  discretion  of  the  physician) ;  sugar ;  potatoes,  rice,  tapioca, 
arrowroot,  sago,  groats ;  peas,  beans ;  sweet  fruits,  as  grapes,  cherries, 
peaches,  apricots,  plums,  and  all  kinds  of  dried  fruits. 

BEVERAGES. 

Champagne  and  sweet  wines  and  beers,  must,  fruit  wines  and  fruit  juices 
and  syrups ;  sweet  lemonade ;  liqueurs ;  ices  and  sorbets ;  cocoa  and 
chocolate. 

Opium,  or  still  better,  codeine,  which  is  said  to  diminish  the  irritability 
of  the  afferent  nerves  of  the  liver,  should  also  be  employed  in  large 
quantities.  The  codeine  is  given  at  first  in  doses  of  a  quarter  of  a  grain 
three  times  a  day,  and  this  may  be  gradually  increased  up  to  five  grains. 
Stimulants  may  also  be  necessary  if  the  pulse  is  becoming  weak,  and  the 
patient  exhausted  ;  the  best  are  dry  wines,  such  as  dry  sherry,  whisky  in 
small  quantities,  etc.,  whilst  sweet  wines,  champagne,  and  the  like  should 
be  strictly  avoided. 

(2)  Local. —  Question  of  amputation.  From  an  early  period  one  must 
consider  the  question  of  amputation.  Formerly  the  rule  was  not  to  ampu- 
tate in  diabetic  gangrene,  partly  on  account  of  the  great  tendency  to 
inflammation  and  suppuration  in  the  stump,  leading  to  extension  of  the 
gangrene,  and  partly  owing  to  the  risk  of  death  from  diabetic  coma. 
Here,  again,  the  rules  have  been  completely  altered  by  the  employment 
of  antiseptic  measures,  and  from  recent  work  it  seems  quite  evident  that 
the  best  treatment  in  most  cases  is  early  amputation.  If  left  alone  the 
great  majority  of  patients  die.  By  strict  asepsis  inflammation  in  the  stump 
is  avoided,  septic  troubles  are  prevented,  and  further  gangrene  does  not 
occur  if  the  amputation  be  performed  sufficiently  high  up.  The  principal 
risk  is  from  diabetic  coma,  and  although  this  may  be  to  some  extent 
increased  by  the  use  of  an  anaesthetic,  more  especially  of  chloroform,  the 
patient  is  not  really  more  liable  to  an  attack  of  diabetic  coma  after 
amputation  than  he  is  during  the  course  of  the  gangrene;  and,  as  he  is 
very  likely  to  die  of  coma  if  not  operated  upon,  this  danger  does  not  seem 
to  present  a  barrier  to  operation. 

(b]  Gangrene  after  acute  Fevers.— Gangrene  from  this  cause  is 
sometimes  a  sequela  of  typhus  or  typhoid  fevers,  and  attacks  the  extremities 
and  the  parts  farthest  from  the  heart,  especially  the  toes,  the  nose,  the 
ears,  and  sometimes  the  fingers.  This  form  of  gangrene  is  generally  due 
to  endarteritis  and  thrombosis  ;  in  some  cases,  however,  it  follows  embolism. 
It  usually  begins  during  the  period  of  convalescence  and  is  dry;  it  is 
unilateral  in  the  case  of  the  extremities. 

Treatment.— The  treatment  is  to  disinfect  the  part,  apply  an  antiseptic 
dressing  (see  p.  64),  and,  in  the  case  of  the  extremities,  to  wait  for  a  line 


78  GANGRENE. 

of  demarcation  before  amputating,  partly  because  the  exact  amount  of  tissue 
that  will  die  cannot  be  known,  and  partly  because  the  patient's  condition 
is  generally  so  bad  at  the  onset  of  the  gangrene  that  amputation  would 
be  very  apt  to  cause  death.  In  addition,  it  is  important  to  support  the 
patients  strength  (see  p.  64)  and  treat  any  symptoms  which  may  arise. 

(<r)  Gangrene  from  Ergot.— This  form  of  gangrene  may  occur  in 
epidemics,  when  the  rye  in  certain  districts  has  become  infected  with  the 
ergot  fungus  (claviceps  purpurea)  and  where  families  eat  large  quantities 
of  this  infected  rye  in  the  form  of  rye-bread.  The  early  effect  of  ergot 
is  to  produce  tetanic  contraction  of  the  smaller  blood-vessels,  and  if  this 
be  kept  up  for  a  long  time,  it  may  lead  to  gangrene,  more  especially  of 
the  extremities. 

Certain  symptoms,  such  as  diarrhoea,  buzzing  in  the  ears,  cramps,  cold- 
ness of  the  extremities,  etc.,  precede  the  occurrence  of  gangrene.  The 
affection  most  usually  attacks  men  between  thirty  and  forty  years  of  age. 
The  form  of  gangrene  is  usually  dry,  but  in  certain  cases  it  may  be  moist, 
and  it  may  vary  in  extent  from  the  loss  of  a  nail  to  the  loss  of  a  limb. 

The  treatment  consists,  in  the  first  instance,  in  removing  the  cause. 
If  there  are  the  premonitory  symptoms  of  ergot  poisoning,  or  the  epidemic 
occurrence  of  gangrene  in  young  patients  who  are  otherwise  healthy,  the 
food  must  be  examined,  and  if  the  claviceps  be  present,  untainted  bread 
must  be  substituted.  Great  attention  should  be  paid  to  the  nutrition  of 
the  patient,  and  the  use  of  strong  coffee  is  highly  recommended  as  an 
antidote. 

As  regards  the  local  treatment  when  gangrene  has  set  in,  the  patient 
must  be  kept  in  bed,  and  the  part  disinfected  and  kept  aseptic;  but  before 
deciding  on  amputation  a  line  of  demarcation  should  be  waited  for,  because 
it  is  impossible  to  say  how  much  of  the  tissue  will  die.  As  a  rule  the 
line  of  demarcation  when  it  has  once  formed  is  permanent,  and  therefore, 
as  soon  as  it  is  well-marked,  the  best  method  of  fashioning  the  flaps  can  be 
decided  upon  and  amputation  performed  without  any  further  delay. 

C.  Infective  Gangrene. — The  third  great  group  of  gangrene  is  that 
due  to  specific  infective  organisms.  In  former  days,  as  the  result  of  sepsis, 
a  variety  of  gangrenous  processes  attacked  wounds,  but  they  are  very  seldom 
seen  now.  It  will  be  sufficient  if  we  speak  here  of  three  forms  of  specific 
gangrene,  namely:  (i)  acute  traumatic  gangrene;  (2)  phagedena,  and  (3) 
cancrum  oris  or  noma. 

(i)  Acute  Traumatic  Gangrene. — This  is  a  form  that  attacks 
wounds  and  is  due  to  the  growth  of  bacteria  in  the  tissues;  it  especially 
attacks  wounds  which  have  been  soiled  with  earth.  It  is  probably  due  to 
a  bacillus  resembling  that  which  produces  symptomatic  anthrax  in  cattle 
and  malignant  cedema  in  some  of  the  lower  animals.  The  disease  begins 
soon  after  the  accident,  usually  about  the  second  or  third  day.  Its  course 
is  as  a  rule  very  rapid,  averaging  about  three  days  before  the  death  of  the 
patient;  the  part  becomes  greatly  swollen  and  cedematous  and  crepitates 


PHAGEDENA. 


79 


from  the  presence  of  gas  which  is  developed  in  the  tissues  in  enormous 
quantities. 

Treatment. — The  first  point  in  the  treatment  is  prophylaxis.  Where 
wounds  are  soiled  with  earth  or  dirt  especial  care  should  be  taken  to  dis- 
infect them,  and  the  best  plan  is  to  place  the  patient  under  an  anaesthetic, 
to  scrub  out  the  earth  with  a  nail  brush  and  the  strong  mixture,  and  then 
to  apply  undiluted  carbolic  acid  to  the  whole  surface  of  the  wound.  It 
must  be  remembered  that  acute  traumatic  gangrene  is  not  the  only  disease 
which  results  from  soiling  of  wounds  with  earth,  malignant  oedema  and 
above  all  tetanus  being  very  often  produced  in  a  similar  manner.  Hence 
thorough  disinfection  of  such  wounds  is  imperative. 

Local  Treatment. — In  acute  traumatic  gangrene  of  the  extremities,  when 
the  disease  has  once  been  established,  amputation  offers  the  only  chance 
of  saving  the  patient.  Almost  all  the  patients  attacked  by  this  affection 
die,  and  unfortunately  even  with  amputation  only  about  5  per  cent,  recover, 
because,  unless  at  a  very  early  stage,  it  is  extremely  difficult  and  often 
impossible  to  get  above  the  disease.  In  amputating,  the  very  greatest  care 
must  be  taken  to  disinfect  the  skin  and  more  especially  to  avoid  soiling 
the  amputation  wound  with  the  discharge  from  the  gangrenous  part. 
Hence,  in  addition  to  the  ordinary  disinfection  of  the  skin  at  the  seat 
of  amputation,  the  gangrenous  extremity  should  be  wrapped  up  in  anti- 
septic gauze  which  has  been  wrung  out  of  the  strong  mixture,  and  this 
is  firmly  fastened  round  the  limb,  well  above  the  upper  limit  of  the 
gangrene,  so  that  none  of  the  contents  of  the  bullae,  etc.,  can  run  out. 
This  is  done  by  an  assistant  who  is  not  afterwards  allowed  to  take  any 
part  in  the  operation.  In  operating  on  these  cases  the  use  of  strychnine 
and  the  other  measures  employed  in  the  prevention  of  shock  (see 
Chap.  VI.),  should  be  especially  attended  to. 

The  general  treatment  consists  in  the  free  administration  of  stimulants 
and  a  generous  diet. 

(2)  Phagedena. — The  second  form  of  specific  gangrene  is  phagedena, 
a  disease  practically  never  seen  nowadays,  but  formerly  very  common, 
especially  in  times  of  war.  It  is  undoubtedly  a  parasitic  affection,  but  the 
exact  nature  of  the  organism  is  unknown.  It  consists  essentially  in  the 
production  on  the  wound  of  a  pseudo-membranous  material,  beneath  which 
the  tissues  ulcerate  or  become  gangrenous,  and  two  forms,  namely,  an 
ulcerative  and  a  gangrenous  one,  are  usually  described.  In  the  ulcerative 
form  a  pulpy  membrane  appears  on  the  surface  of  the  wound ;  beneath 
this,  cup-like  losses  of  substance  occur,  and  subsequently  rapid  ulceration 
takes  place  along  the  planes  of  the  tissues.  In  the  other  form,  the  wound 
becomes  covered  with  a  thicker  membrane,  which  is  dark  coloured,  very 
pulpy,  extending  rapidly,  leading  to  sloughing  of  the  skin  and  muscles, 
and  not  uncommonly  attacking  the  vessels  and  giving  rise  to  severe 
haemorrhage.  The  disease  spreads  with  great  rapidity,  and  the  patient  dies 
in  from  twenty-four  to  forty-eight  hours. 


8o  GANGRENE. 

Treatment. — The  prophylactic  treatment  consists  of  strict  antiseptic 
precautions  in  cases  of  all  wounds,  isolation  of  the  affected  individual,  and 
great  care  not  to  infect  other  persons  with  the  instruments,  or  by  the 
attendants. 

In  the  local  treatment  the  chief  reliance  is  placed  on  destruction  of 
the  pulpy  material,  either  by  the  application  of  the  actual  cautery,  or  by 
the  use  of  nitric  acid  (see  p.  59)  or  perchloride  of  iron,  the  pure  liquor 
ferri  perchloridi  being  employed.  Of  these  the  actual  cautery  seems  to  be 
the  most  efficacious.  The  parts  are  very  thoroughly  destroyed  with  the 
cautery  at  white  heat,  wherever  there  is  the  slightest  suspicion  of  the 
presence  of  the  membranous  material.  After  the  surface  has  been  des- 
troyed with  the  cautery,  the  wound  should  be  packed  with  boracic  lint  dipped 
in  1-5  carbolic  oil.  If  perchloride  of  iron  be  used  the  wound  should  be 
first  thoroughly  dried,  and  lint  soaked  in  the  perchloride  packed  into  it 
and  left  for  four  and-twenty  hours,  after  which  it  may  be  dressed  with 
the  boracic  lint  and  carbolic  oil.  The  perchloride  of  iron  has  not  a 
very  powerful  effect  in  this  disease  and  should  only  be  employed  where 
it  is  slight  in  extent  and  is  not  spreading  rapidly.  If  the  part  affected 
be  an  extremity,  amputation  should  be  performed,  provided  it  be  possible 
to  get  well  above  the  disease.  Naturally,  great  care  must  be  taken  not 
to  infect  the  stump  at  the  same  time. 

In  any  case,  the  general  condition  of  the  patient  should  be  attended  to, 
stimulants,  strychnine,  etc.,  being  freely  administered,  and  every  effort 
made  to  maintain  the  patient's  strength. 

(3)  Cancrum  Oris. — The  third  form  of  specific  gangrene  to  which  we 
shall  refer  is  cancrum  oris,  a  disease  affecting  children,  and  beginning 
in  the  mouth  or  the  vulva  (when  it  is  termed  "noma.").  This 
disease  generally  attacks  weakly  children  of  from  two  to  five  years  of  age, 
who  are  convalescing  from  some  other  affection,  such  as  measles  or  scar- 
latina. In  the  mouth,  it  usually  begins  in  the  gums  ;  the  patient  complains 
of  pain,  the  breath  becomes  foetid,  and  there  is  increased  flow  of  saliva. 
Ulceration  then  occurs  about  the  gums,  a  black  spot  appears  inside  the 
cheek,  and  by  and  by  this  extends  through  the  cheek,  a  slough  forms, 
and  large  portions  of  the  jaw  and  cheek  may  be  destroyed.  The  patient's 
general  condition  is  very  serious,  the  temperature  is  high,  and  death  usually 
occurs  in  from  three  to  four  days.  The  disease  is  due  to  long  delicate 
bacilli  which  are  found  in  large  numbers  in  the  slough,  and  more  especially 
in  the  living  tissues  just  beyond  it. 

The  treatment  aims  at  destroying  all  the  affected  parts,  and  the  portions 
of  the  living  tissues  around  in  which  the  bacilli  are  present.  All  the  parts 
which  are  gangrenous  must  be  clipped  away ;  not  only  the  soft  parts,  but 
the  portion  of  the  jaw  affected  must  be  removed,  and  this  should  be 
done  till  a  surface  which  bleeds  everywhere  is  exposed.  Having  in 
this  way  got  rid  of  all  the  gangrenous  tissues,  pressure  is  applied  and  the 
bleeding  arrested,  and  then  strong  nitric  acid  is  painted  over  or  rubbed  into 


CANCRUM    ORIS.  8l 

the  raw  surface.  This  is  best  done  by  means  of  a  stout  glass  rod  or  a 
glass  brush.  The  acid  is  allowed  to  act  for  about  ten  minutes,  fresh 
applications  being  repeatedly  made  during  that  time.  When  the  surgeon 
is  thoroughly  satisfied  that  every  portion  of  the  disease  is  destroyed,  the 
action  of  the  acid  is  arrested  by  the  application  of  a  saturated  solution  of 
carbonate  of  soda,  which  is  poured  on  the  part  until  the  acid  is  completely 
neutralized,  as  is  shown  when  bubbles  of  carbonic  acid  gas  cease  to  form. 
Anything  short  of  this  treatment  will  fail  in  arresting  the  disease. 
To  leave  the  sloughs  on  the  surface  and  to  apply  antiseptic  washes 
or  strong  antiseptics  to  them  is  absolutely  useless,  for  the  regions  in 
which  the  organisms  are  growing  are  the  living  tissues  just  beyond  the 
actually  dead  parts,  and  these  cannot  be  reached  unless  the  slough 
be  first  removed.  The  part  should  then  be  powdered  with  iodoform, 
and  full-strength  boracic  ointment  spread  on  butter-cloth  applied  with 
boracic  lint  outside  it.  The  mouth  or  vagina  should  be  washed  out  with 
sanitas  and  water  (about  i  part  in  12)  several  times  a  day.  The  wound 
will  begin  to  granulate  in  five  or  six  days,  and  then  the  weaker  boracic 
ointment  may  be  substituted.  Stimulants  are  necessary,  and  also  nourishing 
diet,  and  probably,  at  first,  strychnine  will  be  required.  Great  deformities 
are  left  after  this  disease,  especially  in  the  cheek,  but  these  will  be  dealt 
with  when  we  come  to  consider  the  plastic  surgery  of  the  face  and  jaw. 


CHAPTER    V. 

ANAESTHETICS. 
BY  DR.   J.   FREDK.  W.   SILK. 

THE  two  chief  objects  in  placing  a  patient  under  an  anaesthetic,  are  the 
abolition  of  pain  and  the  diminution  of  shock;  of  but  slightly  less 
importance,  from  the  surgeon's  point  of  view,  are  quietness  and  muscular 
relaxation.  To  attain  these  ends,  a  general  anaesthetic,  by  which  is  meant 
the  inhalation  of  some  particular  gas  or  vapour,  is  almost  essential.  Shock, 
quietness,  and  muscular  relaxation  are,  no  doubt,  partly  dependent  upon 
the  amount  of  pain  inflicted,  and  in  certain  selected  cases,  therefore,  local 
anaesthesia  by  means  of  hypodermic  injections  of  cocaine,  or  the  infiltra- 
tion method  of  Schleich,  or  freezing,  may  be  sufficiently  satisfactory.  As 
far  as  our  present  knowledge  goes,  however,  no  method  is  at  once  so 
certain,  so  universally  applicable,  and  so  complete  as  that  of  general 
anaesthesia  by  inhalation. 

PART   I. 
GENERAL   ANESTHESIA. 

Preliminary  Observations. 

Preparation  of  the  Patient. — With  the  possible  exception  of  nitrous 
oxide  (see  p.  87),  experience  leads  us  to  believe  that  an  anaesthetic  is 
always  taken  better  if  the  patient  has  been  subjected,  for  a  few  days,  to 
what  may  be  termed  hospital  regime.  This  does  not  of  necessity  mean 
absolute  confinement  to  bed,  but  it  implies  rest  of  body  and  mind,  careful 
regulation  of  the  ordinary  bodily  functions,  light  and  easily  digested  diet, 
abstention  from  alcohol,  etc.  Obviously,  it  is  not  always  possible,  nor 
even  advisable,  to  submit  every  patient  to  such  restraint ;  for  instance, 
young  children  and  highly  neurotic  adults  are  often  best  kept  in  ignorance 
of  an  impending  operation,  but  such  patients  frequently  give  trouble  under 
an  anaesthetic,  and  so  confirm  the  value  of  the  general  rule. 

It  has  been  suggested  that  a  course  of  some  drug,  such  as  strychnine, 
quinine,  iron,  etc.,  is  a  sure  safeguard  against  some  of  the  difficulties  and 


PRELIMINARY   OBSERVATIONS.  83 

dangers  which  may  arise  during  the  administration  of  an  anaesthetic.  The 
tonic  properties  of  such  substances  are,  no  doubt,  of  value,  but  it  has 
not  yet  been  proved  that  any  of  them  possess  a  specific  action  in  the 
matter. 

A  purge,  in  the  shape  of  castor  oil,  compound  liquorice  powder,  calomel, 
colocynth,  or  compound  rhubarb  pill,  should  always  be  given  the  night 
before  the  operation,  and,  if  necessary,  an  enema  in  the  morning ;  this 
may  consist  either  of  plain  water  or  soap  and  water.  The  latter  is  made 
by  rubbing  up  Castile  soap  in  warm  water  until  a  thick  lather  is  formed, 
and  about  a  pint  is  injected. 

Diet. — Of  greater  consequence  is  the  axiom  which  insists  upon  an 
empty  stomach  ;  but  starvation  may  be  carried  too  far,  especially  in  the 
feeble.  Each  case  should  be  treated  upon  its  merits,  according  to  the 
digestive  capacities  and  general  health  of  the  individual,  and  bearing  in 
mind  that  the  mere  dread  of  the  operation  will  often  retard  the  digestion 
for  hours.  The  best  time  for  operating  is  the  early  morning,  in  which  case 
no  food  need  be  given  after  supper  on  the  previous  evening.  If  the 
operation  be  fixed  for  the  afternoon  (at  or  after  i  P.M.),  a  light  breakfast 
may  be  taken  not  later  than  8  A.M.,  and  a  cup  of  hot  broth  or  beef  tea, 
or  even  hot  water  alone,  may  be  given  not  less  than  three  clear  hours 
before  the  actual  time  of  operation ;  this  is  useful  in  counteracting  the 
feeling  of  exhaustion  and  faintness,  of  which  many  persons  complain  if 
kept  fasting  too  long.  Milk  and  other  slowly  digestible  substances  should 
always  be  avoided. 

In  cases  of  special  gravity,  either  from  the  condition  of  the  patient 
or  the  probable  severity  of  the  operation,  it  will  be  found  useful  to  give, 
when  possible,  a  nutrient  enema  (yolk  of  one  egg,  one  ounce  each  of 
beef-tea,  milk,  and  brandy,  peptonised,1  if  the  patient  be  particularly  ex- 
hausted), half  an  hour  before  he  is  placed  upon  the  table,  care  being 
taken  to  wash  out  the  rectum  with  warm  water  before  the  enema  is 
injected. 

Alcohol. — Physiologically  or  clinically  considered,  the  use  of  brandy  by 
the  mouth  is  irrational,  as  it  encourages  the  tendency  to  retching  and 
vomiting,  and  increases  the  poisonous  effects  of  the  anaesthetics.  It  may 
become  necessary,  however,  in  cases  of  impending  syncope,  and  in  some 
few  instances  its  administration  may  have  a  good  moral  effect,  but,  as  a 
general  rule,  it  is  not  desirable. 

Hypodermic  medication  immediately  before  the  inhalation,  has  been 
advocated,  the  drugs  used  being  morphine,  atropine,  strychnine,  digitaline, 
etc.  The  routine  use  of  morphine,  even  in  combination  with  atropine,  is 
deprecated  by  most  anaesthetists ;  its  advantages  are  more  theoretical  than 

1  To  peptonise,  add  15  gr.  Bicarbonate  of  Soda  and  a  dessertspoonful  of  Benger's  Liquor 
Pancreaticus  or  5  gr.  of  Fairchild's  Zymine.  Place  the  jar  containing  the  mixture  in  a  basin 
of  water  as  hot  as  the  hand  can  bear  (about  150°  F. ).  Allow  it  to  remain  for  half  an  hour, 
then  heat  it  quickly  to  boiling  point  for  one  minute.  Cool  before  injecting. 


84  ANESTHETICS. 

practical,  and  its  tendency  to  mask  the  symptoms  of  over-narcosis  has  more 
than  once  led  to  fatal  results.  Something  may  be  said  in  its  favour,  when 
used  in  such  special  operations  as  those  involving  the  cerebral  hemispheres, 
where  it  may  help  to  keep  the  parts  anaemic,  but  even  then  only  a  small 
dose  should  be  employed  (£-£  gr.).  There  seems  to  be  some  reason 
for  believing,  that  strychnine  is  of  considerable  value  in  obviating  or 
diminishing  what  may  be  termed  "operation  shock,"1  and  it  is  also  claimed 
by  some,  that  the  tendency  to  sickness  is  lessened  by  its  use.  In  the 
feeble,  therefore,  and  in  severe  operations,  ^  grain  may  be  injected,  either 
immediately  before  or  immediately  after  anaesthesia  is  induced,  and  the 
dose  may  be  repeated  once  or  twice  during  the  course  of  the  operation  ; 
this  does  no  harm,  and  may  do  a  great  deal  of  good. 

Before  the  inhalation  is  commenced,  every  care  must  be  taken  to  re- 
move anything  that  may  interfere  in  the  slightest  degree  with  the  most 
absolute  respiratory  freedom ;  even  in  normal  sleep  the  least  pressure  on 
the  chest  may  cause  an  immense  amount  of  discomfort  Plugs  of  tobacco, 
artificial  teeth,  obturators,  etc.,  should  be  removed,  lest  they  fall  into  the 
larynx  or  pharynx  ;  collars,  stays,  belts,  waistbands,  braces,  bandages,  etc., 
etc.,  must  be  completely  relaxed. 

In  some  instances,  auscultation  of  the  chest  and  heart  increases  the 
trepidation  of  the  patient,  and,  in  by  far  the  majority  of  cases,  the  infor- 
mation obtained  is  valueless  or  misleading;  on  account  of  nervousness 
the  rate  and  rhythm  of  both  cardiac  and  breath  sounds  are  much  interfered 
with,  and  the  accurate  detection  of  slight  lesions  becomes  almost  impossible. 
Although  auscultation  is  not  to  be  recommended  as  a  routine  practice,  the 
•  anaesthetist  is  bound,  nevertheless,  to  acquaint  himself,  through  the  medical 
attendant,  or  through  the  patient  and  his  friends,  with  all  points  in  the 
medical  history  of  the  case  which  may  have  any  bearing  upon  the  question 
of  the  anaesthetic,  especially  in  connection  with  the  respiratory  and  cir- 
culatory systems ;  in  cases  of  doubt,  or  if  the  slightest  desire  for  it  be 
manifested  by  the  patient  or  his  friends,  a  careful  examination  should,  of 
course,  be  undertaken.  It  will  probably  help  to  calm  the  patient  if  the 
pulse  be  felt,  although  but  little  real  information  is  gained  beyond  detecting 
any  marked  thickening  or  atheroma  of  the  arterial  walls. 

The  position  of  the  patient  on  commencing  the  inhalation,  must 
vary  slightly  under  different  circumstances.  Fussy  attempts  to  "  arrange " 
the  patient  are  to  be  deprecated,  and,  generally  speaking,  the  best  rule  to 
adopt  is,  to  allow  the  patient  to  assume  the  recumbent  posture  most  con- 
venient and  comfortable  to  himself.  In  most  instances  this  will  be  supine, 
when,  especially  if  there  be  any  tendency  to  emphysema,  the  head  and 
shoulders  should  be  well  supported  with  pillows.  With  the  patient  sitting 
up  (nitrous  oxide  or  ether),  care  must  be  taken  that  the  head  is  placed  in 

1  Prof.  Wood  of  Philadelphia,  Transactions  of  the  International  Medical  Congress, 
Berlin,  1890,  vol.  I.,  p.  133. 


PRELIMINARY   OBSERVATIONS.  85 

such  a  position  that  the  tongue  does  not  fall  back  over  the  glottis.  In 
some  few  cases,  the  patient  naturally  assumes  the  lateral  position,  and  in 
this  the  anaesthetist  should  acquiesce.  The  great  object  in  view  is,  to 
make  the  necessarily  disagreeable,  preliminary  stages,  as  short,  and  as  little 
unpleasant  as  possible. 

The  choice  of  the  Anaesthetic. — To  a  considerable  extent  the 
comfort  of  both  patient  and  operator,  and  to  some  extent  the  actual  safety 
of  the  patient,  depends,  not  only  upon  the  skill  of  the  administrator,  but 
also  upon  the  particular  anaesthetic  used.  As  far  as  the  choice  of  the 
anaesthetic  fs  concerned,  the  patient,  the  operator,  and  the  anaesthetist 
himself  are  all  factors  which  have  to  be  considered  before  making  the  final 
selection,  so  that  it  is  almost  impossible  to  do  more  than  lay  down  very 
general  rules  ;  each  individual  case  must  be  decided  upon  its  own  merits. 

In  the  first  place,  it  is  obvious,  that  rules  that  are  intended  for 
those  with  whom  it  is  not  a  matter  of  absolutely  every-day  experience  to 
administer  an  anaesthetic,  cannot  have  the  same  weight  when  applied 
to  the  specialist.  An  example  of  this  is  seen  in  the  use  of  ether. 
When  plenty  of  practice  in  the  administration  of  this  drug  is  obtain- 
able, it  may  be  given  in  the  majority  of  cases  ;  but,  on  the  other  hand, 
when  only  used  very  occasionally,  the  results  are  apt  at  first  to  be  dis- 
appointing, unless  the  cases  are  carefully  selected.  In  the  second  place, 
some  surgeons  object  to  the  use  of  particular  anaesthetics  in  certain 
operations.  For  example,  some  surgeons  consider  that  chloroform  alone 
should  be  given  in  abdominal  cases,  while  most  anaesthetists  are  of  opinion 
that  ether  does  equally  well.  In  cases  such  as  these,  it  is  probably  to  the 
best  interests  of  the  patient  to  adopt  the  views  of  the  surgeon  ;  the  latter 
ought  not  to  be  allowed  to  feel,  or  even  to  imagine,  that  his  work  would 
have  been  better  done,  had  a  different  anaesthetic  been  used.  In  the 
third  place,  it  may  be  laid  down  as  an  axiom,  that  it  is  unwise  to  employ 
a  stronger  anaesthetic  than  is  absolutely  necessary.  The  relative  strength 
of  the  various  substances  may  be  assumed  to  be  as  follows,  commencing 
with  the  most  feeble,  viz.  :  nitrous  oxide,  ether,  diluted  chloroform  (the 
A.C.E.  and  other  mixtures),  and  pure  chloroform. 

Factors  determining  choice  of  Anaesthetic. — In  choosing  an  anaesthetic, 
the  most  important  of  the  determining  factors  are  those  which  concern 
the  patient  himself,  and  the  nature,  etc.,  of  the  operation  to  be  performed ; 
these  must,  therefore,  be  considered  a  little  more  in  detail.  A  distinction, 
too,  must  be  drawn  between  the  anaesthetic  with  which  it  is  advisable 
to  induce  or  commence  the  anaesthesia,  and  that  with  which  it  is  possible 
to  maintain  or  continue  it. 

(i)  Duration  of  the  Operation. — Nitrous  oxide  is  available  in  short 
operations  of  under  two  or  three  minutes.  These  include  such  operations 
of  minor  surgery  as  opening  superficial  abscesses,  dilating  and  slitting  up 
sinuses,  some  tenotomies,  removing  small  aural  polypi,  passive  movement 
of  stiff  joints,  and,  of  course,  the  extraction  of  teeth. 


86  ANESTHETICS. 

(2)  Position  of  the  Patient. — Neither  chloroform,  nor  any  mixture  con- 
taining that  drug,  should  be  used  with  the  patient  sitting  up  in  a  chair  ; 
such  a  proceeding  is  absolutely  unjustifiable.     Operations  upon  the  cerebral 
hemispheres,   and   upon   the   mouth   and   tongue,   do   not   really  constitute 
exceptions  to  this  general  rule,  for  although  the  body  is  then  often  raised, 
the  feet  and  legs  remain  horizontal ;  even  in  these  cases  too,  the  more  nearly 
horizontal  the  patient  can  be  brought  the  better. 

(3)  Age  of  the  Patient. — Some   anaesthetists   see   no  objection  to  the 
use  of  ether  at  any  age,  while  others  prefer  to  induce  narcosis  with  chloro- 
form in  the  very  young,  and  continue  with  ether  afterwards.     Until  sufficient 
facility  in  the  use  of  ether  has  been  acquired,  and  unless  one  has  constant 
practice  with  the  drug,  it  is   better  to  adopt  some  such  age-limits  as  the 
following : 

Under  3  years  of  age,       .         .         .       Chloroform  all  through. 

From  3  to  12, A.C.E.  all  through. 

From  12  to  60,          ....       Ether  all  through. 

Over  60, Induce  with  A.C.E.,  inci  easing  the  pro- 
portion of  ether  in  long  operations. 

It  is  usually  asserted,  somewhat  dogmatically,  that  children  always  take 
chloroform  well.  It  must  not  be  forgotten,  however,  that  many  accidents 
have  occurred,  and  that  in  the  opinion  of  some  people  the  death-rate  with 
children  is  as  high,  or  even  higher,  than  with  adults.  This  apparent  im- 
munity of  children  from  fatal  accidents  under  chloroform,  is  due  to  many 
causes,  among  which  may  be  mentioned  the  undoubted  fact  that,  owing  to 
their  greater  vitality,  children  respond  more  readily  than  adults  to  any 
efforts  that  are  made  in  the  direction  of  resuscitation. 

(4)  Condition  of  the  Patient. — Here,  again,  some  anaesthetists  admit  of 
but  few  exceptions  to  the  use  of  ether,  only  perhaps  acute  lung  troubles, 
but,  at  first  at  any  rate,  better  results  will  be  obtained  if  the  range 
of  exceptions  is  somewhat  enlarged. 

In  the  fat  and  plethoric,  .  .  .  Induce  with  A.C.E.,  and  gradually  in- 
crease the  proportion  of  ether  in  long 
operations. 

Acute  or  very  recent  lung  troubles,  .       Chloroform  all  through. 

Chronic    lung    trouble    (bronchitis   or 

emphysema),  .         .         .         .  A.C.E.  all  through. 

Organic  heart  disease,        ...       If  insufficiently  compensated  (pulmonary 

oedema,  anasarca,  albumen,  etc.), 
A.C.E.  or  chloroform.  If  fully  com- 
pensated, ether  permissible. 

Marked  Atheroma,    ....       Induce  with  A.C.E.  ;   add  a  little  ether 

if  the  operation  be  a  prolonged  one. 

Renal  Disease, A.C.E.  all  through. 

Alcoholics  take  all  anaesthetics  badly.  In  acute  or  advanced  cases  it 
is,  perhaps,  better  to  commence  with  A.C.E.,  and  gradually  increase  the 
proportion  of  ether  as  the  case  proceeds. 


ADMINISTRATION    OF   NITROUS   OXIDE.  8/ 

(5)  Nature  of  the  Operation. — To  a  great  extent,  the  influence  of  the 
nature  of  the  operation  upon  the  choice  of  the  anaesthetic,  must  be  largely 
determined  by  the  opinion  of  the  surgeon  upon  the  subject.  It  is,  therefore, 
a  point  of  no  little  importance  that  the  latter  should  have  complete  confi- 
dence in  the  administrator.  The  careful  selection  of  the  administrator 
is  a  question  of  the  greatest  moment,  and  not  to  be  dismissed  lightly ; 
to  take  any  one  that  offers  is  very  unjust  to  the  patient,  and  accounts  for 
many  of  the  troubles  and  fatalities  which  are  from  time  to  time  recorded. 

Operations  upon  the  head  and  neck,  A.C.E.  to  induce,  increasing  the  propor- 
tion of  ether  in  long  operations. 

Intra-cranial  operations,     .         .         .       Chloroform  or  A.C.E.  all  through. 

Operations  upon  the  tongue  and  mouth,  Induce  with  A.C.E.  ;  change  for  chloro- 
form directly  operation  commenced. 

Operations  on  big  joints,  .         .         .       Always  ether,  if  possible. 

Abdominal  operations,  .  .  .  Do  well  with  ether,  but  chloroform  or 

A.C.E.  often  preferred  by  surgeons. 

Rectal  and  genito-urinary  operations,       Always  ether,  if  possible. 

In  practice,  the  choice  of  the  anaesthetic  may  be  quickly  determined  by 
adopting  a  process  of  exclusion,  taking  the  different  substances  in  the 
order  of  their  relative  strength  as  given  on  p.  85.  Commencing  with 
Nitrous  Oxide,  the  reasons  for  and  against  each  drug  may  be  rapidly 
worked  out  in  accordance  with  the  above  tables. 


Administration  of  Nitrous  Oxide. 

Properties. — The  chemical  constitution  of  Nitrous  Oxide  is  sufficiently 
indicated  by  the  formula  N2O.  It  is  a  gas,  but  is  usually  sold  in  a 
highly  compressed,  liquid  form,  in  steel  or  iron  bottles  (Fig.  18,  A).  The 
gas,  when  pure,  should  be  quite  colourless,  of  a  slightly  sweetish  taste  and 
odour,  and  unirritating  to  the  air  passages.  It  is  a  feeble  anaesthetic,  and 
is  usually  given  without  any  admixture  with  air,  i.e.  100  per  cent,  of  the 
vapour. 

Cases  Suitable. — Broadly  speaking,  anyone  can  take  nitrous  oxide  with 
comparative  safety.  It  is  better,  perhaps,  not  to  administer  it  within  an 
hour  or  so  of  a  full  meal,  and  care  should  be  taken  that  the  bladder  is 
empty,  especially  in  children,  but  otherwise,  no  special  preparation  is  needed, 
beyond  that  which  is  necessary  to  ensure  free  respiration  (see  p.  84).  It 
is  most  frequently  given  with  the  patient  sitting  straight  up  in  a  chair,  with 
the  head  in  such  a  position  that  the  tongue  does  not  slip  back  over  the 
glottis ;  it  may,  of  course,  be  given  with  the  patient  recumbent.  For  the 
cases  in  which  it  is  specially  applicable,  see  Sec.  (i),  p.  85.  In  dental 
work,  and  in  operations  about  the  mouth,  it  is  usual  to  insert  a  prop  of 
cork  or  wood  between  the  teeth  before  applying  the  facepiece. 

Although  in  some  respects  an  ideal  anaesthetic,  there  are  many  limita- 
tions to  its  use ;  the  most  important  of  these  is  that,  owing  to  its  feeble 


88 


ANAESTHETICS. 


anaesthetizing  power,  it  is  difficult  to  maintain  the  narcosis  for  any  length 
of  time,  and  practically,  therefore,  its  administration  is  limited  to  cases  in 
which  the  available  anaesthesia  which  follows  the  single  application  of  the 
facepiece  will  suffice.  On  an  average,  this  represents  between  30  and  40 
seconds,  but,  with  a  little  careful  manipulation  and  an  occasional  supply  of 
air,  provided  that  the  operation  is  not  upon  the  mouth,  this  time  can  easily 
be  doubled  or  trebled.  But  even  in  this  short  space  of  time  much  can 
be  done,  and,  as  the  profession  becomes  more  familiar  with  the  drug,  its 
field  of  usefulness  will  be  found  to  be  more  extensive  than  is  generally 
supposed.  Another  objection  to  it  is,  that  the  relaxation  of  the  muscles  is 
usually  very  transitory,  and,  when  the  inhalation  is  pushed,  there  may  be  actual 
spasm  ;  in  moving  stiff  joints,  therefore,  it  is  of  importance  not  to  continue 
the  inhalation  for  too  long  a  time  without  admitting  air. 


FIG.  18. — NITROUS  OXIDE  APPARATUS.    A,  Steel  bottles  containing  compressed  gas 
in  liquid  form ;    B,  Reservoir  bag ;   £,   Facepiece  ;    C,  Three-way  stop-cock  containing 


inspiratory  and  expiratory  valves  ;  F,   Footpiece  for  regulating  escape  of  gas  from  the 
bottles  into  the  reservoir  bag. 

Apparatus  and  Administration. — To  ensure  the  complete  exclusion  of 
air,  the  somewhat  complicated  apparatus,  shown  and  described  in  Fig.  18, 
is  used.  The  bag  B  being  filled  with  gas,  the  administratof  stands  either 
behind  or  on  the  left  side  of  the  patient,  and  carefully  adjusts  the  face- 
piece  E  to  the  irregularities  of  the  face.  Being  satisfied  that  there  is  no 
air  leakage,  the  stop-cock  C  is  turned  on  half-way;  the  nitrous  oxide  is 
then  inspired  from  the  bag,  and  expired  through  the  valves  contained  in 
the  stop-cock  into  the  open  air. 


ADMINISTRATION    OF    NITROUS    OXIDE.  89 

Phenomena. — After  a  very  few  respirations  the  colour  of  the  face  com- 
mences to  change,  becoming  more  and  more  dusky,  or  uniformly  livid. 
Gradually,  too,  the  breathing  becomes  harsher,  and  changes  to  a  regular 
snore,  which,  in  its  turn,  gives  place,  to  an  irregular,  jerky,  laryngeal  stertor ; 
at  or  about  the  same  time,  or  sometimes  even  before  the  laryngeal  stertor 
is  noticed,  twitching  of  the  superficial  muscles  of  the  eyelids,  mouth,  neck, 
etc.,  or  of  the  tendons  of  the  thumbs  and  fingers  will  be  seen ;  and,  if  the 
inhalation  were  to  be  continued  beyond  this,  well-marked  jactitation  of  the 
limbs,  or  even  opisthotonic  spasm  of  the  whole  body,  would  result.  Usually, 
but  not  always,  the  pupils  dilate,  and  the  conjunctivae  may  or  may  not 
become  insensitive  to  touch,  but  the  eye  reflex  is  not  a  reliable  sign 
of  the  sufficiency  of  the  anaesthesia.  Whichever  is  first  observed,  the  irre- 
gular laryngeal  stertor,  or  the  twitching  of  the  muscles  and  tendons,  is  the 
indication  for  withdrawing  the  facepiece.  After  the  facepiece  has  been 
withdrawn,  the  first  few  breaths  of  air  are  followed  by  a  reactionary  redness 
or  blush  about  the  face,  etc.,  and  this  is  an  important  landmark  for  the 
administrator;  not  until  it  occurs  is  he  quite  free  from  anxiety. 

Complications. — The  action  of  nitrous  oxide  is  really  remarkably 
uniform,  and  complications  rare ;  but  still  it  must  be  borne  in  mind  that 
accidents  have  happened,  and  that  deaths  have  occurred  both  from  syncope 
and  asphyxia.  It  should  be  a  rule,  therefore,  to  keep  a  finger  on  the 
temporal  pulse,  both  during  the  inhalation,  and  until  the  reactionary  flush 
occurs ;  if  the  pulse  disappear,  the  patient  should  be  at  once  put  in 
the  recumbent  position,  and  the  ordinary  treatment  for  syncope  adopted. 
Asphyxia  may  be  due  to  a  foreign  body,  e.g.  a  tooth,  and  it  also  seems 
likely  to  occur  in  patients  suffering  from  a  condition  of  more  or  less 
acute  inflammation  of  the  fauces  and  trachea.  In  asphyxiated  patients,  the 
first  thing  to  do  is  to  pass  the  finger  well  to  the  back  of  the  throat  to 
free  the  air-way,  and  to  see  if  perchance  a  foreign  body  can  be  felt  and 
removed.  Failing  this,  the  patient  should  first  be  bent  sharply  forward, 
and  encouraged  to  cough  by  patting  the  back,  etc:;  if  this  does  not  give 
relief,  he  may  be  turned  over  on  the  side,  and, '  if  this  fails,  the 
question  of  tracheotomy,  or  better,  laryngotomy  will  have  to  be  considered. 
Hysterical  patients  sometimes  give  trouble  by  struggling  and  screaming; 
this  is  best  overcome  by  compressing  the  reservoir  bag,  and  so  forcing  the 
gas  into  the  lungs,  taking  care,  of  course,  to  cut  off  the  action  of  the 
valves  in  the  stop-cock.  Children  and  anaemic  girls  are  apt  to  pass  quickly 
and  deeply  under  the  influence  of  the  gas,  and  to  become  opisthotonic ;  the 
facepiece,  therefore,  should  be  removed  immediately  the  slightest  twitching 
or  stertor  occurs. 

The  after-effects  of  nitrous  oxide  may  be  said  to  be  practically  nil,  and 
this  is  one  of  its  great  advantages.  Neurotic  patients  are  sometimes 
hysterical,  very  rarely  there  is  a  little  sickness,  but,  in  by  far  the  majority  of 
cases,  the  patient  is  quite  able  to  leave  the  house,  or  walk  about  within  ten 
minutes  or  a  quarter  of  an  hour  of  the  inhalation. 


90  ANESTHETICS. 

PROLONGED  NITROUS  OXIDE  ANESTHESIA. —Various  plans  have,  from 
time  to  time,  been  suggested  for  increasing  the  anaesthetising  power  of  the  gas. 
In  operations  not  involving  the  mouth  or  nose,  the  anaesthesia  may  often  be  much 
prolonged  by  allowing  the  patient  an  occasional  breath  of  air  directly  the 
twitching  appears.  In  dental  and  other  mouth  cases,  the  supply  of  nitrous 
oxide  may  be  maintained  by  means  of  a  cap  fitted  over  the  nose,  as  suggested  by 
Coleman  and  Patterson,  or  a  tube  may  be  passed  into  the  mouth,  or  down 


D 


FIG.  19. — HEWITT'S  APPARATUS  FOR  THE  ADMINISTRATION  OF  NITROUS  OXIDE 
AND  OXYGEN.  A,  Steel  cylinders  containing  compressed  oxygen  and  liquid  nitrous 
oxide ;  F,  A  double  tube,  one  within  the  other,  conveying  the  respective  gases  (O  and 
N.>O)  to  the  double  reservoir  bag  B  and  D  ;  C,  Stop-cock  by  which  oxygen  is  allowed  to 
pass  through  minute  holes  at  the  same  time  that  the  nitrous  oxide  is  turned  on  ;  E, 
Facepiece. 

the    nose,    and   connected    with   the   reservoir  bag,  as  proposed    by    Hillier    and 
Coxon.1 

Adopting  the  view  that  the  lividity,  muscular  twitching,  and  some  of  the 
other  phenomena  are  indications  of  asphyxia,  or  more  properly  speaking,  of 
oxygen  starvation,  and  assuming  that  these  phenomena  are  always  objectionable, 

1  See  Transactions  of  the  Society  of  Ancesthetists,  vol.  I.,   1898. 


ADMINISTRATION    OF   ETHER.  91 

it  has  been  proposed  to  administer  a  mixture  of  nitrous  oxide  and  oxygen.  The 
quantity  of  oxygen  required  is  very  small,  and  the  chief  difficulty  has  hitherto 
been  in  designing  a  method  and  an  apparatus  for  practical  use.  Dr.  Hewitt, 
after  much  patient  labour  and  many  experiments,  has  produced  the  apparatus 
shown  in  Fig.  19.  The  facepiece  being  accurately  adjusted,  the  nitrous  oxide 
mixed  with  the  oxygen  from  one  or  two  holes  is  breathed  from  the  beginning, 
and  the  amount  of  oxygen  is  cautiously  increased  by  a  hole  at  a  time  as  the 
inhalation  proceeds.  The  indications  for  removing  the  facepiece  are  a  faint 
stertor,  fixation  of  the  eyeball,  and  insensibility  of  the  conjunctivse.  The  plan, 
excellent  as  it  is,  requires  constant  practice  before  anything  like  uniform 
results  are  obtained,  and,  in  common  with  the  other  methods  referred  to,  is 
open  to  the  objection  that  unpleasant  after-effects  are  more  likely  to  follow, 
than  is  the  case  when  nitrous  oxide  is  administered  in  the  manner  suggested 
in  the  text. 

In  the  above-mentioned  plans,  it  is  sought  to  prolong  the  inhalation  of  the 
feeble  anaesthetic,  nitrous  oxide,  by  preventing  the  development  of  the  asphyxial 
symptoms.  A  similar  result  may  be  obtained  by  mixing  the  gas  with  some 
other  and  more  powerful  anaesthetic,  such  as  ether.  This  is  what  is  known 
as  the  "combined"  or  "  gas-and-ether "  method  of  anaesthesia,  which  will 
be  referred  to  after  the  administration  of  ether  has  been  described  (see  p.  97). 


Administration  of  Ether. 

Properties. — The  chemical  formula  of  ethylic  ether  is  C4H10O ;  it  is 
sometimes  known  as  sulphuric  ether.  It  is  usually  recommended  to 
employ  only  that  made  from  absolute  alcohol ;  but  of  late  years  many 
excellent  brands  have  been  placed  on  the  market,  and,  if  carefully 
selected,  their  use  seems  unobjectionable.  The  substance  employed 
should  have  a  specific  gravity  of  720;  it  should  be  neutral  to  test-paper, 
and,  on  being  burnt  off  or  evaporated  from  a  white  surface,  should  leave 
behind  neither  colour  nor  disagreeable  smell.1  The  so-called  "anaesthetic 
ether"  of  chemists  is  intended  only  for  local  purposes  (freezing),  and 
should  never  be  used  for  inhalation.  The  vapour  of  ether  is  highly  inflam- 
mable, and  even — when  mixed  with  air  or  nitrous  oxide — explosive.  Its 
anaesthetic  strength  is  such,  that  over  30  per  cent,  of  the  vapour  is 
necessary  to  produce  narcosis  within  a  reasonable  time  (Snow,  "  On  Anaes- 
thetics "). 

Cases  suitable. — For  reasons  into  which  it  is  unnecessary  to  enter, 
it  is  considered  by  many  that  ether  can,  and  should  be  employed  whenever 
an  anaesthetic  is  called  for ;  practically,  the  only  exceptions  which  are 
then  admitted,  are  those  in  which  bronchitis,  or  some  other  more  or  less 
acute  lung  trouble  is  present,  or  when,  as  in  operations  about  the  mouth, 

1 A  continuous  decomposition  is  said  to  go  on  at  the  exposed  surface  of  the  liquid, 
the  results  being  objectionable.  To  obviate  this,  it  has  been  suggested  that  a  small  quantity 
of  metallic  mercury  should  be  kept  in  each  bottle ;  an  insoluble  black  oxide  of  mercury 
is  then  formed,  from  which  the  pure  ether  can  be  decanted  as  required  (Prof.  Ramsay, 
Soc.  of  Ancesthelists,  Nov.,  1898).  I  have  myself  given  this  suggestion  a  prolonged  trial. 
There  can  be  no  doubt  as  to  the  formation  of  the  black  oxide,  but  I  am  not  quite 
convinced  that  the  clinical  value  of  the  ether  is  improved. 


92  ANESTHETICS. 

it  is  either  physically  impossible  to  apply  the  facepiece,  or  else  there 
is  some  danger  that  the  actual  cautery  will  ignite  the  vapour.  For  the 
reasons  given  above  (see  p.  85),  this  universal  use  of  ether  is  at  first  likely  to 
prove  disappointing  in  the  hands  of  those  whose  training  and  practice  has 
not  thoroughly  accustomed  them  to  the  drug.  When  only  occasionally 
called  upon  to  anaesthetise,  it  is  better  for  the  administrator  to  limit  his  use 
of  ether  in  accordance  with  the  suggestions  already  made  (see  p.  86).  If 
these  lists  be  carefully  studied,  it  will  be  seen  that  ether  is  not  recommended 
for  children  under  twelve,  or  for  adults  over  sixty ;  nor  for  the  fat  and 
plethoric ;  nor  for  those  suffering  from  gross  cerebral  lesions ;  nor  in  cases 
of  lung  disease ;  nor  in  acute  heart  disease,  atheroma,  or  renal  disease ; 
nor  in  operations  about  the  head  and  neck,  mouth  and  tongue.  At  first 
sight,  it  may  appear  that  this  list  of  exceptions  reduces  the  available  cases 


FIG.  20. — CLOVER'S  SMALL  OR  PORTABLE  ETHER  APPARATUS.  C,  Ether  chamber  ; 
.S,  Opening  through  which  the  chamber  is  rilled  with  2  ozs.  of  ether  ;  f,  Padded  facepiece  ; 
B,  Reservoir  bag  ;  p,  Pointer  or  index,  which  is  a  fixture.  To  increase  the  proportion  of 
ether  inhaled,  the  chamber  is  rotated  so  as  to  bring  the  figures  i,  2,  etc.,  over  the  index  in 
succession. 

to  a  minimum,  but  in  practice  this  will  not  be  found  to  be  the  case, 
and,  further,  it  must  be  pointed  out,  that  in  by  far  the  majority  of  cases 
the  objection  applies  rather  to  the  primary  induction ;  in  nearly  all  it  is 
possible  to  use  ether  to  maintain  the  anaesthesia. 

Ether  should  always  be  given,  if  possible,  in  cases  involving  much 
shock,  and  in  which  a  profound  degree  of  narcosis  is  required,  as  in 
operations  about  the  rectum,  on  the  genito-urinary  tract,  or  on  big  joints. 
Operations  upon  the  abdomen  are  on  the  border-line,  and  the  anaesthetic 
chosen  must  be  largely  determined  by  the  predilection  of  the  surgeon 
(see  p.  85). 

With  regard  to  the  preparation  of  the  patient,  nothing  need  be 
added  to  what  has  already  been  said  upon  the  subject  (see  p.  82).  It  is 


ADMINISTRATION    OF   ETHER. 


53 


one  of  the  advantages  of  ether  which  is  sometimes  overlooked,  that,  if 
need  be,  it  can  be  administered  to  a  patient  sitting  up,  without  very  much 
additional  risk ;  preference  should,  however,  always  be  given  to  the 
recumbent  position,  as  the  increased  muco-salivary  secretion  can  then 
be  got  rid  of  more  easily. 

Apparatus  and  Administration. — In  an  emergency,  an  inhaler  for 
ether  can  be  made  by  twisting  two  or  three  folds  of  brown  paper  into 
a  cone,  like  a  grocer's  sugar-bag,  pinning  the  folds  together,  pushing  a 
wide-meshed  sponge  well  up  into  the  apex  of  the  cone,  tearing  off  the 
extreme  tip  to  admit  air,  and  shaping  the  mouth  of  the  bag  to  fit  over 
the  nose  and  chin ;  the  ether  is  poured  upon  the  sponge.  Of  course, 
better  results  will  be  obtained  when  a  properly  constructed  inhaler  is  used. 
In  Fig.  20  the  well-known  Clover's  (small  and  portable)  Inhaler  is  shown. 
Two  ounces  of  ether  are  poured  into  the  ether  chamber  through  the 
opening  S.  The  inner  tube,  with  the  facepiece  attached,  is  thrust  up 
through  the  corresponding  opening  in  the  ether  chamber,  the  index  / 
carefully  adjusted  to  the  mark  0  on  the  body  of  the  chamber,  and  the 
facepiece  f  placed  over  the  mouth  and  nose  of  the  patient.  After  a  few 
breaths  have  been  taken,  and  the  patient  has  become  accustomed  to  the 
apparatus,  the  bag  B  is  fixed  on  to  the  end  of  the  tube  which  will  be 
found  flush  with  the  upper  opening  in  the  ether  chamber.  A  few  breaths 
in  and  out  of  the  bag  are  allowed,  and  then,  during  an  expiration,  the 
body  of  the  chamber  is  gently  rotated,  either  to  the  right  or  to  the  left, 
for  the  space  of  about  a  quarter  of  an  inch,  or  even  less ;  a  few  more 
breaths  being  allowed,  another  rotation  of  about  the  same  extent  is  made. 
These  movements  are  repeated  at  short  intervals  until,  finally,  the  index 
points  to  about  the  3,  at  which  position  it  is  maintained  until  a  sufficiently 
profound  degree  of  narcosis  is  obtained.  Each  movement  of  the  ether 
chamber  should  be  a  little  larger  than  that  which  immediately  precedes  it, 
should  be  made  during  an  expiration,  and  no  additional  onward  movement 
should  take  place  so  long  as  coughing,  spasm,  or  other  indication  that  the 
vapour  is  producing  undue  irritation  is  present.  It  is  seldom,  if  ever, 
necessary  to  give  a  greater  strength  of  vapour  than  that  indicated  above, 
and,  in  fact,  when  the  primary  skin  incisions  have  been  made,  and  the 
patient  has  become  quiet,  and  saturated  with  ether,  it  is,  in  many  cases, 
advisable  to  diminish  the  strength  of  the  vapour  by  turning  the  ether 
chamber  back  to  the  2,  or  even  to  the  i. 

Another  very  useful  and  somewhat  simpler  form  of  apparatus  is  that 
known  as  Ormsby's  Inhaler,  shown  in  section  in  Fig.  21.  In  this  inhaler 
the  means  for  regulating  the  strength  of  the  vapour,  even  approximately, 
are  not  very  accurate,  and,  consequently,  it  requires  some  practice  before 
it  can  be  used  with  certainty.  The  great  point  is,  to  commence  with  only 
a  drachm  or  two  on  the  sponge  at  first,  and  to  allow  a  free  entrance  of 
air  through  the  valve  and  under  the  edge  of  the  facepiece,  until  the  patient 
becomes  thoroughly  accustomed  to  the  drug. 


94 


ANAESTHETICS. 


For  the  sake  of  convenience  of  description,  it  is  usual  to  divide  the 
process  of  anaesthetisation  into  four  stages,  but,  of  course,  it  must  be  under- 
stood, that  this  arrangement  is  somewhat  artificial ;  clinically,  the  different 
stages  merge  into  and  overlap  one  another,  and  are  not  equally  well  defined 


IN     PRACTICE 
THIS  BAG  SHOULD    BE 
LARGER  THAN    IS    HERE 

REPRESENTED 


FIG.  21. — SECTIONAL  VIEW  OF  ORMSBV'S  ETHER  INHALER.  B,  Padded  facepiece,  at 
the  apex  of  which  is  fitted  a  wire  cage  (dotted  line),  for  holding  the  sponge  upon  which 
the_ether  is  poured.  Over  this  cage  and  its  contained  sponge  a  large  india-rubber  bag, 
A,  is  fitted.  At  C  is  an  arrangement  which  admits  of  a  certain  amount  of  regulation  of 
the  air-supply. 

in  every  case.  These  stages  are : — First,  the  stage  of  confusion  of  ideas, 
with  subjective  sensations  of  dizziness,  tingling  of  the  extremities,  etc.; 
second,  the  stage  of  excitement  and  more  or  less  struggling;  third,  the 
stage  of  anaesthesia,  with  flaccidity  of  the  limbs,  slow  movements  of  the 
eyeballs  from  side  to  side,  abolition  of  the  conjunctival  and  other  super- 
ficial reflexes,  but  the  deeper  reflexes  are  retained,  so  that  there  is  still  the 
power  of  coughing  and  swallowing,  and,  when  the  skin  incisions  are  made 
the  muscles  are  apt  to  be  thrown  into  spasm  ;  the  fourth  stage  is  char- 
acterized by  more  markedly  stertorous  breathing,  dilated  pupils,  fixation  of 
eyeballs,  and  abolition  of  all  reflexes,  both  superficial  and  deep.  As  a 
general  rule,  the  fourth,  or  most  profound  degree  of  anaesthesia,  is  kept  up 
only  until  the  primary  incisions  have  been  made,  after  which  the  patient 
may  be  allowed  to  fall  back  to  the  third  degree ;  but  in  cases  where  con 
siderable  shock  is  to  be  anticipated,  as  in  operations  upon  the  abdomen, 
on  the  large  joints,  in  the  genito-urinary  areas,  etc.,  it  is  of  great  importance 
that  the  anaesthesia  should  be  maintained  fairly  deeply  throughout. 


ADMINISTRATION    OF   ETHER. 


95 


There  are  three  special  points  in  connection  with  ether  anaesthesia 
which  must  be  noted.  If  the  vapour  be  introduced  too  rapidly,  or  its 
strength  increased  too  suddenly,  some  temporary  laryngeal  spasm,  with  more 
or  less  coughing  and  straining,  will  very  likely  ensue  ;  if  this  does  not  dis- 
appear in  the  course  of  a  few  respirations,  air  must  be  admitted  and  the  pro- 
portion of  vapour  diminished.  It  is  generally  possible  to  induce  anaesthesia 
with  but  little  alteration  in  the  colour ;  for  the  first  four  or  five  minutes, 
however,  some  slight  lividity  is  excusable,  but  it  is  quite  a  mistake  to  sup- 
pose that  persistent  and  marked  blueness  is  of  necessity  associated  with 
the  use  of  ether ;  such  a  condition  means  either  bad  administration,  or 
that  the  patient  is  not  a  fit  subject  for  this  particular  drug.  Directly  the 
colour  commences  to  change,  air  must  be  admitted  beneath  the  edge  of 
the  facepiece,  and  if,  in  spite  of  the  free  admission  of  air,  the  lividity  per- 
sists, or  sufficiently  profound  anaesthesia  cannot  be  obtained,  it  is  wisest  to 
change  the  anaesthetic.  The  third  point  is,  that  as  the  patient  passes  under 
the  influence  of  the  vapour,  there  is  a  considerable  increase  in  the  flow  of 
mucus  and  saliva ;  as  soon,  therefore,  as  the  muscles  of  the  neck  become 
sufficiently  relaxed,  the  head  must  be  turned  to  one  side,  so  as  to  en- 
courage this  excessive  secretion  to  flow  into  the  cheek,  and  so  out  of  the 
mouth. 

The  essential  characteristic  of  ether  anaesthesia  is  the  stimulation.  The 
respirations  increase  in  frequency  and  depth,  and,  partly  on  account  of  the 
presence  of  mucus  in  the  air  passages,  they  are  usually  noisy.  The  pulse 
becomes  quicker,  of  greater  volume,  and  improved  in  tone  ;  an  erythe- 
matous  flush,  (ether  rash)  often  appears  over  the  neck,  chest,  and  arms, 
and  may  be  so  well  marked,  and  so  extensive,  as  to  be  mistaken  at  first 
sight  for  one  of  the  exanthemata.  The  pupils  are  widely  dilated  during 
the  stage  of  excitement  and  struggling,  moderately  contracted  during  the 
comparatively  light  anaesthesia  of  the  middle  of  the  third  stage,  but  tending 
to  dilate  as  the  narcosis  becomes  deeper ;  unless  this  dilatation  takes  place 
very  suddenly,  it  is  not  of  necessity  a  sign  of  danger,  as  in  the  case  of 
chloroform. 

The  chief  dangers  in  connection  with  the  administration  of  ether  are 
of  an  asphyxial  type.  The  muco-salivary  secretions  may  be  so  excessive 
that  the  lungs  may  become  "water-logged,"  the  heart's  action  seriously 
embarrassed,  and  the  venous  system  engorged.  The  careful  administrator 
ought  never  to  allow  a  patient  to  get  into  this  serious  condition ;  the  free 
admission  of  air,  or  if  this  fails,  the  substitution  of  another  anaesthetic 
should  not  be  delayed  when  once  the  tendency  is  apparent.  The  accumu- 
lation of  mucus  may  often  be  checked  at  the  outset  by  permitting  the 
patient  to  come  round  just  sufficiently  to  allow  of  his  swallowing,  or  even, 
when  it  is  permissible,  vomiting.  If,  however,  the  condition  of  "water- 
logging "  has  arisen  the  anaesthetic  must  be  withheld,  the  mouth  opened, 
the  tongue  pulled  forward,  the  mucus  sponged  out  from  the  throat,  vomiting 
encouraged,  and  finally,  the  patient  must  be  turned  on  his  right  side  ;  it  is 


96  ANAESTHETICS. 

in  such  cases  as  these,  that  the  administration  of  oxygen  is  especially 
called  for.  In  the  earlier  stages  of  ether  narcosis,  primary  cardiac  syncope 
seldom  if  ever  occurs  as  a  direct  result  of  the  inhalation,  although,  of  course, 
the  mere  dread  of  the  operation  may  have  this  affect ;  on  the  other  hand, 
cases  are  on  record  in  which  death,  occurring  at  a  later  period,  appears 
to  have  been  due  to  over-stimulation  of  the  heart,  and,  perhaps,  of  the 
respiratory  centre.  If,  then,  while  the  patient  is  well  under,  the  breathing 
becomes  more  rapid  and  shallower,  the  inhalation  should  be  suspended 
for  a  short  time  until  the  normal  condition  is  restored. 

With  either  the  Clover's  or  the  Ormsby's  inhaler,  the  time  occupied  in 
producing  anaesthesia  must,  of  course,  vary  very  considerably  ;  from  four  to 
six  minutes  may  be  taken  as  a  good  working  average.  From  a  calculation 
based  upon  277  cases,  in  which  both  the  duration  of  the  operation,  and  the 
quantity  of  ether  used  was  noted,  one  ounce  of  ether  was  estimated  to 
last,  on  an  average,  io'95  minutes.1 

After-effects.— If  the  patient  has  not  been  more  than  about  a  quarter  of 
an  hour  or  twenty  minutes  under  the  anaesthetic,  he  passes,  on  discontinu- 
ing the  inhalation,  through  the  stages  already  referred  to  (see  p.  94),  but  in 
reverse  order,  viz.,  comparatively  light  anaesthesia,  excitement,  gradually  re- 
turning consciousness.  In  any  event,  one  of  the  first  after-effects  is  usually 
the  vomiting  of  mucus,  often  frothy  and  ropy,  and  frequently  bile-stained. 
With  ether,  this  is  apt  to  be  very  severe  during  the  first  hour  or  two,  but 
as  the  patient  is  but  partly  conscious,  it  is  really  less  distressing  to  him 
than  at  first  sight  appears.  As  soon  as  he  can  do  so,  the  patient  should 
be  encouraged  to  wash  out  his  mouth  with  warm  water,  and  sips  of  hot 
water  should  be  swallowed.  In  some  cases,  especially  if  there  has  been 
little  or  no  sickness,  more  or  less  violent  delirium  is  observed.  The  fre- 
quency with  which  serious  pulmonary  troubles  occur  after  the  use  of  ether 
has  probably  been  greatly  exaggerated.  On  the  other  hand,  there  can  be  no 
doubt  that  the  inhalation  of  ether  renders  the  lungs  particularly  susceptible 
to  alterations  in  temperature,  draughts,  etc.  Consequently,  some  bronchial 
irritation  may  occasionally  follow  the  inhalation.  It  is  wise,  therefore,  to 
order  that  the  temperature  of  the  room  should  not  be  allowed  to  drop 
below  65°  F.,  that  screens  should  be  placed  round  the  bed,  and  that  for 
the  first  few  hours  at  any  rate,  the  patient  should,  if  possible,  be  kept  lying 
on  one  side,  by  preference  the  right.  This  latter  manoeuvre  not  only  assists 
the  escape  of  saliva,  etc.,  from  the  mouth,  but,  I  believe,  also  facilitates  the 
onward  flow  of  the  mucus,  etc.,  through  the  pylorus,  and  so  diminishes  the 
tendency  to  retching  and  sickness.  Occasionally,  "  water-logging,"  and  the 
effects  of  over-stimulation  (see  p.  95)  do  not  manifest  themselves  until  after 
the  patient  has  been  put  back  to  bed,  and  fatal  results  have  been  recorded 
from  these  causes  at  this  stage ;  patients  should,  therefore,  be  strictly 
watched  by  a  responsible  person,  for  at  least  an  hour  or  more  after  the 

1  King's  College  Hospital  Reports,  Vols.  II.,  III.,  and  IV. 


COMBINED    METHOD. 


97 


completion   of    the   operation.     For    a    more    detailed    reference    to    after- 
treatment  see  p.   1 1 6. 

Nitrous   Oxide    and    Ether    Combined.  —  The  so-called  COMBINED 

METHOD  is  the  plan  of  inducing  anaesthesia  with  nitrous  oxide,  and  main- 
taining the  narcosis  with  ether  (nitrogenizing  the  ether).  The  procedure  is  as 
follows,  viz.: — If  the  Clover's  inhaler  be  used,  the  three-way  tube  and  bag  of 
the  nitrous  oxide  apparatus  are  substituted  for  the  smaller  ether-bag  (Fig.  22). 


FIG.  22. — CLOVER'S  PORTABLE  ETHER  APPARATUS,  FITTED  FOR  NITROUS  OXIDE 
AND  ETHER  COMBINED.  A,  Steel  gas  bottles  ;  B,  Reservoir  bag;  C,  Three-way  stop- 
cock connecting  gas  bag  ;  D,  Ether  chamber ;  E,  Facepiece. 


About  half  a  dozen  full  respirations  of  the  nitrous  oxide  are  allowed,  and  then  the 
ether  vapour  is  cautiously  admitted  by  rotating  the  ether  chamber.  When  once  the 
ether  is  tolerated,  the  increase  in  the  strength  of  the  vapour  may  be  much  greater, 
and  made  at  shorter  intervals  than  when  ether  alone  is  being  administered. 
When  irregular  stertor  and  twitching  of  the  muscles  appear,  the  nitrous  oxide 
must  all  be  pressed  out  of  the  bag,  and  a  breath  or  two  of  air  given,  or  perhaps 
a  better  plan  is  to  change  the  large  for  the  smaller  bag  at  this  stage.  If  the 
Ormsby's  inhaler  be  used  for  the  ether,  the  patient  is  first  anaesthetised  with 

G 


ANESTHETICS. 

the  apparatus  figured  on  page  88,  and  directly  the  irregular  stertor  and  twitching 
appear,  an  Ormsby's  inhaler,  fully  charged  with  an  ounce  of  ether,  is  rapidly  sub- 
stituted, without  permitting  any  fresh  air  to  be  breathed  ;  the  spasm  caused  by  the 
excessive  strength  of  ether  vapour  is  sometimes  very  pronounced,  but  will  quickly 
pass  off,  and  the  patient  will  rapidly  come  under  the  influence  of  the  ether.  Except 
in  the  hands  of  an  adept,  this  use  of  the  Ormsby's  inhaler  is  difficult,  and  even 
when  the  Clover  is  employed,  a  good  deal  of  practice  is  required  before  uniformly 
satisfactory  results  are  obtained.  The  point  to  be  aimed  at  when  using  the  latter 
apparatus  is  the  turning  on  of  the  ether  at  such  a  rate,  that  a  full  dose  is  being 
inhaled  at  the  precise  moment  when  the  muscular  twitching,  etc.,  due  to  the 
nitrous  oxide,  are  first  observed. 

It  is  claimed  for  these  combined  methods  that  they  are  far  more  pleasant  for 
the  patient,  as  he  is  unconscious  of  the  irritating  and  disagreeable  taste  and  smell 
of  the  ether  ;  that  they  are  much  more  rapid,  induction  only  occupying  about  two 
minutes  as  compared  with  four  to  six  minutes  when  ether  alone  is  used  ;  that  to 
a  great  extent  they  do  away  with,  or  considerably  modify  the  excitement  and 
struggling,  and  so  enable  us  to  dispense  with  the  help  of  others  in  restraining 
the  patient.  That  substantial  advantages  are  to  be  gained  by  adopting  one  or 
other  of  these  plans,  is  sufficiently  proved  by  the  fact,  that  there  are  probably 
but  few  anaesthetists  of  the  present  day  who  do  not  employ  them,  or  who 
habitually  use  ether  alone. 

Ether  is  also  frequently  used  in  dental  work  for  the  purpose  of  intensifying 
the  action  of  nitrous  oxide  (etherizing  the  nitrous  oxide).  The  Clover's  apparatus 
may  be  used  for  this  purpose,  and  the  procedure  is  practically  the  same  as  already 
detailed,  except,  perhaps,  that  the  patient  is  allowed  to  get  more  fully  under  the 
influence  of  the  nitrous  oxide  before  the  ether  is  turned  on,  and  the  ether  is  turned 
on  more  rapidly.  It  is  for  these  cases  that  the  large  Clover  (Fig.  23)  is  particularly 


a, 

^f  ^^      VI 

d 


FIG.  23.— CLOVER'S  LARGE  NITROUS  OXIDE  AND  ETHER  APPARATUS  (modified). 
A,  Facepiece;  c,  Expiratory  valve;  C,  Ether  chamber;  a,  Stopcock  for  bringing  ether 
chamber  into  connection  with  the  tube  £>,  which  in  its  turn  communicates  with  the  face- 
piece.  B  is  a  reservoir  bag  which  may  also  be  used  for  nitrous  oxide  alone,  being  filled 
with  gas  through  the  tap,  b.  When  it  is  desired  to  administer  ether  and  nitrous  oxide  in 
combination,  the  bag  is  filled  with  gas,  the  lap  a  is  turned  on,  and  the  amount  of  ether 
supplied  is  regulated  by  means  of  the  tap  d. 

useful,  as  the  odour  of  ether  can  be  more  perfectly  shut  off  from  the  facepiece, 
and  does  not  diffuse  itself  into  the  room.  I  believe  myself,  that  in  this  use  of 
ether  the  local  effect  of  the  vapour  upon  the  buccal  mucous  membrane,  is  largely 
responsible  for  the  prolongation  of  the  anaesthesia. 


ADMINISTRATION    OF   CHLOROFORM.  99 

Administration  of  Chloroform. 

Strictly  speaking,  one  ought  now  to  describe  the  administration  of 
diluted  chloroform  in  the  shape  of  the  mixtures  (A.C.E.,  etc.),  as  these 
rank  next  above  ether  in  anaesthetic  strength.  For  convenience  in  de- 
scription, however,  and  to  avoid  repetition,  chloroform  ansesthesia  will 
first  be  referred  to. 

Properties. — Chloroform  has  a  chemical  formula  of  CHC13.  Its  spec, 
grav.  should  be  1*497,  and  only  that  made  from  pure  alcohol  should 
be  employed ;  the  so-called  methylated  chloroform  is  inadmissible  for 
anaesthetic  purposes.  Unless  carefully  protected  from  heat  and  sun- 
light, it  is  apt  to  decompose.1  It  should  be  quite  colourless  ;  neutral  to 
test  paper ;  leaving  no  disagreeable  smell  or  coloured  residue  on  evapora- 
tion ;  giving  no  precipitate  with  a  solution  of  nitrate  of  silver ;  and  not 
turning  brown  on  mixing  with  an  equal  volume  of  pure  sulphuric  acid. 
The  vapour  is  upwards  of  four  times  as  heavy  as  air,  uninflammable,  but 
decomposing  into  highly  irritating  gases  when  passed  through  or  brought 
into  contact  with  a  flame.  Hence  it  is  important,  when  operating  at  night, 
or  in  small  rooms  in  the  presence  of  a  naked  flame,  to  secure  a  full  and 
adequate  amount  of  ventilation.  Chloroform  is  the  strongest  anaesthetic 
that  we  possess  ;  above  4  per  cent,  of  the  vapour  constitutes  a  dangerous 
dose. 

With  nitrous  oxide  and  with  ether,  special  means  have  to  be  adopted 
to  obtain  a  sufficient  percentage  of  the  vapour ;  with  chloroform,  on  the 
other  hand,  the  greatest  attention  must  be  paid  to  securing  a  sufficient 
supply  of  air. 

Cases  suitable. — If  the  suggestions  already  made  (see  p.  85)  as  to  the 
alternative  use  of  the  several  drugs  be  adopted,  it  will  be  found  that  the 
use  of  undiluted  chloroform  will  be  limited  to  such  cases  as  the  following, 
viz. — Infants,  and  very  young  children  of  one  or  two  years  of  age;  those 
suffering  from  acute  or  very  recently  acute  lung  trouble ;  in  parturition, 
where  only  a  partial  action  seems  to  be  required  ;  in  operations  about  the 
nose  and  mouth,  to  maintain  the  anaesthesia  induced  by  other  anaesthetics ; 
in  proximity  to  the  actual  cautery,  etc.  Chloroform  enters  largely,  however, 
into  the  composition  of  the  A.C.E.  and  other  mixtures,  so  that  practically 
it  still  retains  a  prominent  place  in  the  list  of  available  anaesthetics. 

The  preparation  of  the  patient  should  be  carried  out  strictly  on  the 
lines  suggested  on  p.  82,  and,  with  regard  to  position,-  an  emphatic  protest 
must  be  entered  against  any  attempt  being  made  to  administer  chloroform 
to  a  patient  sitting  in  a  chair.  This  protest  is  necessary,  because  it  is 
still  occasionally  used  for  tooth  extraction  with  the  patient  in  the  ordinary 

1  The  products  of  decomposition,  as  far  as  they  are  harmful,  are  said  to  be  neutralised 
if  a  small  quantity  of  slaked  lime  be  kept  in  the  chloroform  bottle,  the  pure  chloroform 
being  decanted  off  as  required.  I  have  not,  however,  any  personal  experience  of  the 
value  of  this  proceeding. 


IOO 


ANAESTHETICS. 


dental  position.     When  chloroform  is  inhaled  the  patient  should  always  be 
recumbent. 

Apparatus  and  Administration. — The  simplest  way  to  administer  chloro- 
form, and  at  the  same  time  ensure  a  sufficient  supply  of  air,  is  to  sprinkle 
it  drop  by  drop  by  means  of  a  suitable  drop-bottle  (Fig.  25),  on  to  the  out- 
side of  a  folded  towel  (Fig.  24),  or  on  to  a  handkerchief,  or,  better  still, 
on  to  a  piece  of  domette  stretched  tightly  over  a  metal  frame  (Skinner's 


FIG.  24. — TOWEL  FOLDED  FOR  THE  ADMINISTRATION  OF  CHLOROFORM. 


FIG.  25. — GRADUATED  DROP-BOTTLE  WITH 
HOLLOW  STOPPER. 


FIG.  26. — SKINNER'S  FRAME. 


Inhaler),  Fig.  26.  Personally,  I  strongly  object  to  the  use  of  lint,  the 
woolly  surface  of  which  quickly  becomes  sodden,  and  renders  the  equable 
distribution  of  the  vapour  almost  impossible. 

By  some,  the  Junker's  Inhaler  (Fig.  27)  is  preferred.  The  principle  of 
this  apparatus  is  simply  that  of  blowing  air  through  a  layer  of  liquid  chloro- 
form by  means  of  a  hand-bellows,  the  mixture  of  air  and  vapour  being 
conveyed  to  a  facepiece.  Variations  in  the  strength  of  the  vapour  are 
determined  by  the  force  and  frequency  with  which  the  bellows  are 
pressed.  Care  must  be  taken  that  the  liquid  chloroform  does  not  more 
than  half  fill  the  bottle,  and  that  the  bellows-tube  and  the  exit-tube  are 
fitted  to  their  respective  metal  connections.  Fatal  accidents  have  occurred 
from  neglecting  these  points,  as  liquid  chloroform  is  then  poured  into  the 
patient's  mouth. 


ADMINISTRATION    OF   CHLOROFORM. 


101 


Whichever  method  be  employed,  it  must  be  constantly  borne  in  mind 
that  care  and  vigilance,  on  the  part  of  the  administrator,  are  much  more 
important  elements  of  success  than  is  the  use  of  any  particular  apparatus. 
Excellent  results  may  be  obtained  by  any  plan  that  is  systematically 
studied  and  employed. 

With  chloroform,  as  with  every  other  anaesthetic,  it  is  very  important 
to  commence  the  inhalation  gradually.  The  evaporating  surface  must,  at 
first,  be  held  some  four  or  five  inches  from  the  face,  and  only  brought 
close  over  the  nose  and  mouth  as  consciousness  is  abolished  and  toleration 
established.  If,  as  may  sometimes  happen  even  in  the  earlier  stages,  there 
be  any  retching,  the  anaesthetic  should  be  pressed,  when  the  retching  will 
often  cease;  but  if  vomiting  has  actually  taken  place,  and  the  contents  of 
the  stomach  have  regurgitated  into  the  mouth,  the  anaesthetic  must  be 


FIG.  27. — JUNKER'S  APPARATUS  FOR  THE  ADMINISTRATION  OF  CHLOROFORM.  A, 
Hand-bellows  for  forcing  air  through  the  chloroform  contained  in  the  bottle  B,  and 
thence  into  the  vulcanite  facepiece  C.  D,  Mouth  tube  for  use  with  Junker's  Apparatus  ; 
the  facepiece  C  is  removed  and  the  end  a  of  the  tube  is  slipped  on  to  the  rubber  pipe. 

withdrawn,  the  mouth  opened,  and  the  vomited  matter  removed.  The  stage 
of  excitement  and  unconscious  struggling  requires  careful  management. 
The  condition  of  mental  and  physical  turmoil  is  undoubtedly  a  dangerous 
one,  and  should  not  be  allowed  to  become  unduly  prolonged.  On  the  other 
hand,  the  deep  inspirations  which  the  patient  sometimes  takes  are  apt  to 
overcharge  the  lungs  with  vapour,  and  so  to  lead  to  sudden  respiratory  and 
circulatory  failure.  The  best  plan,  I  believe,  is  to  give  the  anaesthetic  freely 
at  these  times,  but  making  sure,  by  raising  the  inhaler,  etc.,  that  the  amount 
of  air  is  proportionately  increased.  It  is  dangerous,  with  chloroform  especially, 
to  bring  the  inhaler  closer  to  the  face  while  struggling  is  proceeding. 

The  phenomena  observed  during  the  induction  of  anaesthesia  with 
chloroform,  are  very  similar  to  those  already  alluded  to  in  describing  ether 
anaesthesia  (see  p.  94).  The  stage  of  excitement  is  perhaps  less  marked 


102  ANAESTHETICS. 

and  of  shorter  duration,  and  it  is  followed  by  a  period  of  depression,  in 
which  the  blood  pressure  falls,  the  pulse  becomes  smaller  and  weaker,  and 
the  respirations  shallower.  During  the  stage  of  excitement  the  'pupils,  as  a 
rule,  dilate  rather  widely,  and  this  dilatation  may  continue,  especially  in 
young  children  and  in  the  neurotic,  for  a  considerable  length  of  time,  if 
not  during  the  whole  period  of  narcosis ;  usually,  however,  the  pupil  during 
the  third  stage  is  moderately  contracted,  i.e.  rather  smaller  than  with  ether. 
During  the  fourth  stage,  the  pupil  tends  to  dilate,  often  suddenly,  and  this 
is  an  indication  that  the  narcosis  is  of  dangerous  depth.  Then,  again,  a 
rather  widely  dilated  pupil  is  often  the  precursor  of  vomiting,  which  cannot 
of  course  occur  unless  the  patient  be  but  lightly  anaesthetised.  These  alter- 
ations in  the  size  of  the  pupils,  when  rightly  interpreted,  afford  valuable 
information  to  the  administrator,  but  at  the  same  time  it  is  obvious,  that 
we  cannot  rely  upon  the  pupil  phenomena  alone  as  indications  of  the  exact 
state  of  the  patient.  Occasionally  during  induction,  and  especially  in 
children,  the  patient  passes  imperceptibly  into  a  curious  and  anomalous 
condition  of  anaesthetically  induced  sleep,  or  false  aruzsthesia  ;  the  pupils 
are  sharply  contracted,  the  limbs  are  quite  flaccid,  the  superficial  reflexes 
abolished,  and  it  is  not  until  the  deeper  reflexes  are  excited,  as  by  the 
skin  incision,  that  we  are  able  to  recognize  the  fact  that  the  state  is  in 
reality  one  of  light  anaesthesia. 

The  ideal  condition  of  a  patient  under  chloroform  should  be  somewhat 
as  follows,  viz. :  colour  good,  or  slightly  pallid ;  respirations  regular,  fairly 
deep,  slightly  accelerated,  quiet,  or  with  a  slight,  soft  snore ;  eyeballs  fixed 
or  rotating  very  slowly  from  side  to  side,  pupils  moderately  contracted  and 
sluggishly  sensitive,  corneal  conjunctiva;  insensitive.  The  greatest  variations 
from  this  standard  will  be  found  in  the  very  young  and  the  very  old — in 
old  people  the  respirations  and  pulse  rate  may  both  be  very  much  below 
the  average.  It  is  impossible,  however,  to  refer  in  detail  to  all  the  varia- 
tions which  may  be  observed.  Very  occasionally  in  quite  young  infants, 
an  undue  strength  of  vapour  will  give  rise  to  some  slight  laryngeal  spasm. 
Blueness  of  the  lips,  cheeks,  ears,  etc.,  is  quite  unwarranted,  as  it  indicates 
that  the  vapour  is  being  given  in  far  too  great  a  strength,  and  air  must 
at  once  be  supplied ;  some  patients  become  very  pale  under  any  anaes- 
thetic which  contains  chloroform,  and,  if  this  pallor  is  gradually  displaced 
by  an  ashy-grey  hue,  it  is  an  indication  that  the  circulation  is  failing,  and 
the  anaesthetic  must  be  at  once  withdrawn,  and,  if  need  be,  more  energetic 
measures  taken  (see  p.  112).  The  respirations  must  be  watched  with  the 
greatest  possible  vigilance,  and  variations  in  the  rapidity  and  depth  should 
be  detected  early.  Quick,  shallow  breathing  may  end  in  total  cessation  of 
respiration,  and  is  an  indication  for  diminishing  the  strength  of  the  vapour, 
or  even  withdrawing  it  for  a  time  altogether.  The  treatment  to  be  adopted 
when  the  breathing  does  stop  will  be  described  presently  (see  p.  112). 

Pure  chloroform,  unmixed  with  ether,  should  not,  theoretically,  give 
rise  to  noisy  or  stertorous  respirations,  and  certainly  noisy  breathing  which 


ADMINISTRATION    OF   MIXTURES. 


103 


cannot  be  rectified  by  slight  changes  in  the  position  of  the  head,  pushing 
forward  the  base  of  the  tongue,  by  pressure  upon  the  angles  of  the  inferior 
maxilla  or  lifting  the  chin  upwards,  must  not  be  allowed.  There  is  practi- 
cally no  increase  in  the  flow  of  mucus,  etc. 

The  essential  characteristic  of  chloroform  anaesthesia  is  the  depression. 
Thus,  paralysis  of  the  respiratory  centre  is  probably  the  most  usual  cause 
of  death  in  fatal  cases,  though  cardiac  failure  is  not  unknown.  This  tendency 
to  respiratory  failure  sets  in  very  early,  and  makes  it  more  than  usually 
imperative  that  the  respiration  should  be  most  carefully  watched,  at  the 
same  time  as,  but  even  more  vigilantly  than  the  circulation.  It  is  probable 
that  respiratory  failure  is  usually  associated  with  cardiac  failure,  though  not 
always  part  passu.  As  Lord  Lister  has  pointed  out,1  the  breathing  may 
become  obstructed  by  the  falling  together  of  the  relaxed  soft  tissues  about 
the  air  passages,  and  this  condition  has  an  important  bearing  upon  the 
treatment,  as  will  subsequently  be  explained  (see  p.  no). 

On  an  average,  between  six  and  eight  minutes  is  a  fair  time  to  allow 
for  inducing  anaesthesia  with  chloroform  by  the  above  method.  It  is  said 
by  some,  that  the  quantity  of  chloroform  used  should  be  at  about  the  rate 
of  3i.  for  every  ten  minutes  of  anaesthesia,  but  such  estimates  are  un- 
reliable, as  it  is  obvious  that  the  amount  must  vary  enormously  in  accord- 
ance with  such  opposite  conditions  as  the  age  of  the  patient,  his  state  of 
health,  the  heat  of  the  weather,  the  thickness  of  the  towel,  etc.,  etc. 

The  special  after-effects  of  chloroform  differ  in  degree  rather  than  in 
kind  from  those  observed  as  a  consequence  of  the  use  of  ether.  The 
vomiting  may  not  be  so  severe,  but  it  often  does  not  set  in  until  con- 
sciousness is  more  or  less  completely  restored,  and  therefore  the  feeling  of 
wretchedness  is  prolonged.  Bronchitis  and  other  lung  affections  are  rare 
sequelae  to  chloroform  inhalation,  nor  is  delirium  at  all  frequent.  For  a 
more  detailed  account  of  after-treatment  see  p.  116. 

Administration  of  Mixtures  (A.C.E.,  etc.) 

From  the  point  of  view  of  anaesthetic  strength,  the  mixtures  occupy  a 
position  intermediate  between  ether  and  chloroform.  Of  such  mixtures 
there  may,  of  course,  be  an  infinite  variety,  according  to  the  relative  pro 
portion  of  the  constituents,  but  to  certain  stock  mixtures  definite  names 
have  been  attached ;  thus,  a  combination  of  one  part  of  chloroform  to  three 
of  ether  is  known  as  the  "Vienna  mixture,"  while  "Billroth's  mixture"  con- 
sists of  three  parts  of  chloroform,  one  of  ether,  and  one  of  absolute  alcohol. 
In  this  country,  however,  "the  A.C.E.  mixture,"  or,  as  it  is  often  called, 
"  the  mixture,"  is  the  term  by  which  is  usually  indicated  a  fluid  composed  of 
absolute  alcohol  spec.  grav.  795  one  part,  chloroform  spec.  grav.  1*497 
two  parts,  ether  spec.  grav.  '720  three  parts  ;  it  is  usually  looked  upon  as 
merely  a  mechanical  mixture  of  its  constituents. 

1  Holmes'  System  of  Surgery,  vol.   III. 


104  ANAESTHETICS. 

Properties. — Its  spec.  grav.  when  freshly  prepared,  is  as  nearly  as 
possible  the  mean  of  its  three  constituents,  i.e.,  i  ~o ;  the  spec.  grav.  of  its 
vapour  has  not  been  experimentally  determined.  The  particular  purpose 
served  by  the  alcohol  is  not  very  clear ;  possibly  the  advantage  is  mainly 
mechanical,  leading  to  a  more  intimate  admixture  of  the  several  constituents, 
but  it  is  also  claimed  that  the  evaporation  of  the  ether  is  somewhat  re- 
tarded, and  there  is  no  doubt  that,  by  the  use  of  alcohol,  the  vapour 
inhaled  has  a  pleasanter  and  less  pungent  smell  than  when  ether  and 
chloroform  are  alone  employed.  It  is  said  to  be  somewhat  unstable,  and  it 
is  always  recommended  that  it  should  be  freshly  prepared,  as  required. 

Advantages. — The  question  is  often  asked,  why  the  mixture  should  be 
preferred  to  pure  chloroform.  The  reply  to  this  query  is  founded  partly 
upon  theoretical,  partly  upon  practical  considerations.  Theoretically,  I  am 
inclined  to  believe  that  the  stimulating  effects  of  the  ether  vapour,  however 
slight,  cannot  but  be  of  service,  and  that,  by  using  a  moderately  diluted 
vapour,  there  is  much  less  risk  of  overstepping  the  narrow  margin  of  safety 
which  is  so  characteristic  of  chloroform  anaesthesia.  Practically,  I  am  sure 
that,  with  the  mixture,  one  obtains  earlier  notice  of  impending  danger  than 
with  chloroform  alone.  Neither  the  mixture  nor  any  of  the  anaesthetics  at 
present  known  are  absolutely  safe,  but  the  danger  with  the  A.C.E.  is  chiefly 
that  of  over-narcosis  pure  and  simple,  and  of  this  more  ample  warning  is 
given  than  with  chloroform  ;  to  a  great  extent,  though  perhaps  not  entirely, 
the  element  of  sudden  over-dilatation  of  the  heart  is  eliminated. 

Cases  Suitable. — Broadly  speaking,  it  may  be  said  that  when,  for  any 
reason,  neither  nitrous  oxide  nor  ether  are  considered  advisable,  the  next 
string  to  the  bow  of  the  anaesthetist  is  the  mixture.  The  list  of  objections 
to  the  use  of  ether,  therefore,  given  on  p.  92,  constitutes  a  list  from  \vhich 
cases  suitable  for  the  use  of  A.C.E.  can  be  selected.  But  even  the  small 
amount  of  ether  contained  in  the  mixture  may  be  considered  harmful  in 
infants  and  very  young  children ;  in  those  actually  suffering  from  extensive 
lung  disease,  or  when  the  actual  cautery  is  to  be  employed  in  close  proximity 
to  the  inhaler.  As  an  inhaler  is  usually  employed,  it  is  not  easy  to  maintain 
the  narcosis  with  A.C.E.  in  operations  about  the  mouth  and  nose,  though 
even  in  these,  the  anaesthesia  may  easily  be  induced  by  this  means. 

The  preparation  of  the  patient  should  be  carried  out  on  the  lines 
suggested  on  p.  82,  and  no  position  is  permissible  but  the  recumbent, 
or  one  in  which  the  feet  and  legs  are  elevated  to  at  least  the  level  of 
the  body. 

Apparatus  and  Administration. — No  form  of  closed  or  bag-inhaler  of 
the  Clover  or  Ormsby  type  must  be  used  for  A.C.E.  or  other  chloroform 
mixture.  In  very  small  children,  and  in  neurotic  adults  it  may  be  given  by 
the  open  method,  i.e.,  by  dropping  on  the  corner  of  a  towel  or  handkerchief 
held  just  above  the  mouth.  Generally  speaking,  however,  an  inhaler  of  the 
shape  represented  in  Fig.  28  is  desirable.  It  is  important  that  a  very  free 
supply  of  air  should  be  available,  so  the  ventilation  holes  must  be  large  and 


ADMINISTRATION    OF   MIXTURES. 


105 


FIG.  28. — CELLULOID  MASK  FOR 
A.C.E.  Fitted  with  a  bag  of  thin 
flannel  or  domette  in  which  is  placed  a 
full-sized,  open-meshed  sponge.  The 
air  holes  at  the  end  should  be  numerous 
and  large.  The  flannel  bag  and  sponge 
should  be  changed  after  each  case,  and 
the  whole  washed  in  cold  water.  In 
practice,  the  flannel  bag  shouK'  be  much 
longer  than  is  here  represented,  and 
should  go  well  to  the  bottom  of  the 
inhaler. 


numerous,  and  the  facepiece  ought  not  to  fit  over  the  nose  and  mouth 
with  any  great  accuracy,  and  for  this  reason  a  padded  facepiece  is  objection- 
able. In  the  actual  administration  two  points 
are  to  be  particularly  attended  to,  viz. :  Use 
small  quantities  of  the  mixture  frequently 
repeated,  rather  than  one  or  two  large  doses. 
By  this  means,  the  stimulating  effects  of  the 
ether  are  more  nearly  continuous  than  when  a 
large  quantity  of  the  liquid  is  used  at  a  time. 
Secondly,  in  this,  as  in  all  other  methods  of 
inducing  general  anaesthesia,  it  is  important  to 
commence  the  inhalation  very  gradually,  hold- 
ing the  facepiece  a  few  inches  from  the  face  to 
begin  with,  and  gradually  bringing  it  nearer  as 
the  vapour  is  better  tolerated. 

The  chief  objections  which  have  been  urged 
against  the  use  of  the  mixture  are  as  follows, 
viz.  :  In  the  first  place,  it  is  sometimes  said 
that  an  over-strong  vapour,  consisting  chiefly 
of  chloroform,  is  apt  to  accumulate  in  the 
mask  below  the  sponge.  The  possibility  of 
this  occurring  cannot  be  doubted,  and  the 

remedy  is  equally  obvious.  The  mask  must  not  fit  the  face  at  all 
closely,  and  must  be  supplied  with  plenty  of  large  air-holes,  and  the 
anaesthetic  must  be  added  in  small  quantities  (5i.  to  5ii.)  at  a  time. 
Under  this  head,  too,  must  be  included  the  objection,  that  the  different 
constituents  of  the  mixture  evaporate  at  different  temperatures.  This,  of 
course,  is  true,  but  experience  has  shown  that  the  consequent  slight 
variations  in  the  composition  of  the  vapour  do  not  militate  against  the 
practical  efficacy  of  the  mixture.  In  the  second  place,  it  is  objected  that 
the  sponge,  flannel  bag,  etc.,  are  liable  to  become  over-saturated,  especially 
in  long  cases,  and  the  superfluous  liquid  is  then  apt  to  trickle  on  to  the 
face  and  excoriate  the  skin.  Here,  again,  by  a  little  judicious  management, 
the  trouble  can  frequently  be  avoided.  Add  the  mixture  in  small  quantities 
at  a  time,  as  required,  allowing  a  few  seconds  for  it  to  soak  well  into  the 
sponge ;  do  not  use  old,  hard  sponges,  but  large  soft  ones,  taking  care 
that  they  are  well  washed  after  each  administration  ;  in  long  cases,  too,  the 
sponge  should  be  changed  from  time  to  time.  If  the  flannel  bag  be  objected 
to  it  may  be  removed,  and  the  sponge  held  in  place  by  means  of  a  wire 
passed  transversely  through  two  opposite  air-holes.  Perhaps  a  better  and 
more  cleanly  form  of  inhaler  is  the  metal  mask  figured  on  p.  106  (Fig.  29). 
This  apparatus  is  made  of  metal,  and  can  be  purified  in  lotions  or  by  heat. 
The  sponge  is  retained  in  position  by  means  of  a  wire  guard  Fig.  30  (B~) 
and  a  shield  set  at  an  angle  (A)  prevents  the  liquid  from  running  on  to  the 
face.  The  hinged,  perforated,  concave  top  (D}  is  convenient  for  charging 


io6 


AN/ESTHETICS. 


without  removing  from  the  face.  Anaesthesia  may  be  maintained  with  ether 
in  these  masks,  if  necessary,  but  it  is  difficult  and  often  impossible  to  use 
them  for  the  induction  of  ether  anaesthesia. 


--D 


FIG.  29. — METAL  MASK  FOR  A.C.E. 
OR  ETHER. 


FIG.  30. — SECTIONAL  VIEW  OF  METAL  MASK,  shewing 
A,  Shield  or  drip-catcher;  B,  Wire  sponge  guard;  C, 
Sponge  ;  D,  Perforated  hinged  concave  top. 


Bearing  in  mind  that  the  most  potent  constituent  of  the  A.C.E. ,  and 
most  other  mixtures,  is  the  chloroform,  it  is  only  natural  that  the  phenomena 
observed,  and  the  precautions  to  be  adopted  in  their  administration,  are 
but  modifications  of  those  already  described  under  the  head  of  the  latter 
drug.  Owing  to  the  stimulating  effect  of  the  ether,  which  should  be 
almost  continuous  if  small,  frequently  repeated  doses,  mixed  with  plenty  of 
air  be  given,  the  depressing  effects  of  the  chloroform  are  less  apparent. 
On  the  other  hand,  laryngeal  spasm  is  of  slightly  more  frequent  occurrence 
in  children,  and  as  the  flow  of  mucus  is  increased,  the  breathing  is 
apt  to  be  a  little  more  noisy.  The  ether-rash  (see  p.  95)  is  occasionally 
observed,  and  the  pupils  are,  on  the  whole,  inclined  to  be  rather  more 
widely  dilated  than  with  chloroform  in  the  third  stage  of  anaesthesia. 

The  dangers  and  after-effects  are  essentially  those  of  chloroform  (see 
p.  103),  but  as  they  are  rather  more  gradual  in  their  onset,  they  can 
usually  be  detected  before  the  condition  of  the  patient  becomes  serious. 
There  appears  to  be  less  fear  of  early  cardiac  syncope. 

As  a  rule,  about  an  ounce  should  amply  suffice  to  induce  anaesthesia 
in  most  patients,  and  in  children  rather  less  will  be  required.  From  five 
to  seven  minutes  should  be  allowed  for  the  production  of  the  primary 
narcosis.  From  a  calculation  based  upon  988  cases  in  which  both  the 
duration  of  the  operation  and  the  amount  of  mixture  used  was  noted,  one 
ounce  of  A.C.E.  was  estimated  to  last  on  an  average  1776  minutes.1 

ETHER  PRECEDED  BY  A.C.E.—  When,  for  any  reason,  nitrous  oxide 
is  objected  to  as  a  vehicle  for  introducing  ether  by  the  "  combined  method " 
already  referred  to  on  page  97,  the  A.C.E.,  given  on  a  towel,  a  handkerchief, 
or  in  a  mask,  may  be  substituted  for  the  gas  with  advantage.  But  very  little 
mixture  is  necessary  for  this  purpose  (5i.-5ii-)»  the  anaesthesia  is  not  carried 

1  Kings  College  Hospital  Reports,  vols.  II.,  III.,  and  IV. 


SPECIAL   CASES. 


ID/ 


much  beyond  the  end  of  the  first  stage,  just  sufficient  to  abolish  consciousness 
and  stopping  short  of  the  stage  of  excitement  ;  a  fully  charged  ether  inhaler  is 
then  substituted.  In  cases  lasting  more  than  half-an-hour  too,  I  am  in  the  habit 
of  increasing  the  proportion  of  ether  until,  at  last — after  about  an  hour — ether 
alone  is  inhaled,  the  same  mask  being  used  throughout. 

Special  Cases. 

Under  certain  conditions,  some  slight  departure  from  the  ordinary  routine 
methods  of  administration  seems  to  be  desirable,  but  space  will  not  permit 
of  more  than  a  passing  reference  to  these  cases,  and  this  reference  may 
most  conveniently  take  the  form  of  indicating  my  own  practice  in  the  matter. 

In  intra-cranial  operations  I  usually  advise  the  preliminary  in- 
jection of  a  small  dose  of  morphia  (£  to  J  gr.).  Anaesthesia  is  induced  in 
the  recumbent  position,  and  the  body  is  raised  slowly  and  cautiously 
to  an  angle  of  about  45  degrees.  Chloroform  or  the  A.C.E.  is  used 
throughout,  and  only  just  enough  anaesthetic  is  given  to  keep  the  patient 
quiet.  His  disease  and  the  effects  of  the  morphia  combined,  render  him 
very  susceptible  to  an  over-dose,  and  at  the  same  time  make  him  less 
susceptible  to  actual  pain. 

Operations  about  the  Nose  and  Mouth. — In  such  short  opera- 
tions upon  the  nose  as  the  removal  of  spurs  on  the  septum,  turbinated 
bodies,  etc.,  the  operator  often  considers  it  better  for  the  patient  to  be 
sitting  up,  in  which  case,  of  course,  nitrous  oxide,  with  or  without  the 
addition  of  oxygen  or  ether,  is  the  best  anaesthetic,  and  as  soon  as  possible 
the  body  should  be  pushed  well  forward,  so  that  the  head  may  hang  over 
a  basin  placed  between  the  knees,  when  the  blood  will  run  out  of  the  nose 
and  mouth.  .  A  somewhat  similar  position  and  procedure  will,  in  the  opinion 
of  some  surgeons,  suffice  for  the  removal  of  tonsils  or  adenoids,  but  when 
the  choice  is  left  to  the  anaesthetist,  I  must  confess  that  I  have  a  preference 
for  the  plan  of  lightly  anaesthetising  the  patient  in  the  recumbent  position 
with  A.C.E.,  and  turning  him  on  the  right  side  as  the  operation  proceeds. 

Use  of  Junker's  Inhaler  with  Tube. — In  long  operations  about  the  buccal 
cavity,  e.g.,  removal  of  the  tongue,  I  prefer  to  induce  anaesthesia  to  a 
tolerably  profound  degree  with  A.C.E. ,  and  to  maintain  it  with  chloroform 
given  out  of  a  Junker's  inhaler  (Fig.  27)  in  which  the  facepiece  has  been 
removed  and  a  tube  substituted.  The  tube  (Fig.  27  D}  should  have  an 
internal  diameter  of  at  least  four  millimetres  (they  are  generally  much  too 
narrow),  and  may  be  passed  down  the  nose  if  necessary.  Some  adminis- 
trators prefer  to  very  thoroughly  saturate  the  patient  with  ether  for  five  or 
six  minutes  before  the  operation  is  commenced,  and  then,  if  need  be, 
continue  with  chloroform.  My  own  experience  is  that  ether  causes  undue 
congestion  and  bleeding,  and  the  increased  flow  of  mucus  still  further 
obscures  the  field  of  operation,  and  increases  the  tendency  to  asphyxia. 
The  practice  of  different  surgeons  varies  considerably  in  respect  to  the 
position  adopted  for  the  performance  of  these  operations.  Many  surgeons 


i  oS 


ANESTHETICS. 


prefer  that,  whenever  possible,  the  patient  should  be  absolutely  recumbent, 
the  head  being  allowed  to  hang  over  the  end  of  the  table,  with  the  neck 
extended,  so  as  to  bring  the  post-nasal  space  into  a  dependent  position. 
Personally,  I  am  doubtful  whether  much  is  really  gained  by  this,  and  I 
am  quite  sure  that  the  bleeding  is  more  profuse,  and  that  the  stretching 
of  the  muscles  and  tissues  of  the  neck  causes  much  after-discomfort. 
Others,  again,  like  to  have  the  head  and  shoulders  well  raised,  and  perhaps 
the  chin  strongly  flexed  towards  the  sternum.  There  are  still  others  who 
place  the  patient  sitting  almost  bolt  upright.  As  an  anaesthetist  I  am 
convinced  that  the  latter  is  a  most  risky  position,  as  it  tends  to  encourage 
syncope ;  the  other  positions  are  not  objectionable  from  this  point  of  view. 
In  such  delicate  operations  as  those  for  cleft  palate,  the  dorsal  position, 
with  the  head  more  or  less  extended,  is  imperative,  so  that  the  best  view 
possible  of  the  parts  may  be  obtained.  In  these  cases,  too,  some  surgeons 
of  great  experience  consider  that  healing  is  retarded  by  the  direct  impact 

A 


FIG.  31.— HAHX'S  TRACHEAL  TAMPON-  AND  CHLOROFORM  ATTACHMF.VT.  E, 
Trachea!  tube,  covered  with  sponge  which  swells  up  in  the  trachea.  B,  Metal  cone 
covered  with  domette  on  which  the  chloroform  is  dropped.  D,  F,  C,  A,  Tube  conveying 
vapour  to  tracheal  tube  on  which  it  is  fixed  at  a.  It  is  of  importance  that  the  junctions 
D,  C,  and  A  be  sufficiently  large  (for  adults  6-8  mm.) ;  in  the  tubes  sold  they  are  often 
much  too  small. 

of  the  chloroform  vapour  from  the  tube  upon  the  freshly  cut  edges  of  the 
wound,  and  they  prefer  to  maintain  the  anaesthesia  by  means  of  chloroform 
dropped  upon  a  towel  or  lint ;  but  direct  impact  of  the  vapour  ought  to 
be  easily  avoided,  and  when  this  is  done  it  is  difficult  to  understand  why, 
if  the  patient  be  kept  well  under,  the  use  of  the  towel  or  lint  should  be 
less  injurious. 

In  using  the  Junker's  apparatus  where  the  breathing  is  likely  to  be 
obstructed,  it  is  important  to  bear  in  mind,  that  the  heavy  vapour  of 
chloroform  is  apt  to  accumulate  at  the  back  of  the  throat,  directly  the 
breathing  becomes  in  the  slightest  degree  obstructed,  so  that  the  energy 
with  which  the  bellows  should  be  worked  must  be  directly  proportionate  to 
the  freedom  of  respiration. 

In  extensive  operations  upon  the  base  of  the  tongue,  etc.,  when  pre- 
liminary tracheotomy  is  advisable,  a  Hahn's  or  Trendelenburg's  tampon  is 


SPECIAL   CASES. 


109 


inserted  (Fig.  31),  the  anaesthesia  being  then  maintained  through  the 
tracheal  opening. 

Patients  with  enlarged  thyroids  are  very  liable  to  sudden  attacks 
of  syncope  while  taking  anaesthetics,  but,  on  the  other  hand,  it  is  really 
remarkable  what  a  very  small  quantity  of  anaesthetic  will  suffice  to  keep 
such  patients  thoroughly  under.  In  thyroidectomies,  therefore,  I  frequently 
use  a  Junker's  apparatus  throughout,  giving  but  very  little  of  the  anaesthetic, 
only  just  enough  to  restrain  the  retching  and  vomiting  to  which  such 
patients  appear  to  be  particularly  prone.  Abroad,  local  anaesthesia  in  the 
shape  of  cocaine  is  largely  employed  in  these  operations,  but  it  appears 
to  me  to  be  quite  possible,  that  the  success  of  this  drug  in  these  cases  is 
in  some  measure  due  to  the  difference  in  the  type  of  the  patients,  as 
compared  with  those  seen  in  this  country. 

In  all  these  operations  about  the  head  and  neck,  some  trouble  is 
experienced  in  preventing  the  hair  from  falling  into  the  wound,  and  in 
keeping  the  blood  from  the  hair.  I  have  adopted  the  device  shown  and 
explained  in  Figs.  32  and  33. 


FIG.  33- 


FIGS.  32  and  33.- — PROTECTION  OF  THE  HAIR  IN  OPERATIONS  ABOUT  THE  HEAD 
AND  NECK.  The  middle  of  the  folded  edge  of  a  carbolised  towel  (Fig.  32)  is  placed  over 
the  forehead,  carried  down  over  the  ears,  the  ends  A  and  B  crossed  behind  the  occiput, 
and  then  brought  over  the  forehead  again.  The  points  C  may  be  used  for  including  the 
stray  ends  of  hair.  The  appearance  will  be  as  in  Fig.  33. 

In  severe  operations  in  which  much  shock  is  to  be  anticipated, 
it  is  of  importance  that  the  anaesthesia  should  be  tolerably  profound 
throughout.  Among  such  operations  I  would  particularly  enumerate  those 
affecting  the  big  joints,  those  involving  manipulation  of  the  spermatic  cord, 
operations  upon  the  genito-urinary  and  rectal  areas,  and  abdominal  opera- 
tions. When  patients  are  losing  much  blood,  or  are  suffering  from  primary 
shock  or  much  prostration,  the  strength  of  the  vapour  inhaled  may  be 
considerably  diminished. 

Alcoholics  are  troublesome  subjects  to  anaesthetize.  They  are  apt  to 
struggle  very  violently,  to  become  very  livid,  and  unless  reduced  to  a 
dangerous  degree  of  narcosis,  they  are  often  very  restless.  This  is  especially 
the  case  when  ether  is  used.  Their  tissues  are  often  much  degenerated, 
so  that  in  choosing  an  anaesthetic  for  such  patients  it  must  be  remembered 
that  they  are  prematurely  aged.  Acute  or  far  advanced  cases  should 
perhaps  be  started  with  A.C.E.,  and  ether  gradually  added. 


1 10  ANESTHETICS. 

Difficulties  and  Dangers. 

Difficulties  and  dangers  directly  connected  with  the  anaesthetic,  are  due 
to  the  effects  of  the  various  drugs  upon  either  the  respiratory,  or  the 
circulatory  systems.  Many  and  bitter  are  the  controversies  which  have  arisen 
as  to  which  system  is  primarily  affected,  but  much  of  this  discussion  has 
been  of  an  academic  rather  than  of  a  practical  character ;  at  present,  the 
balance  of  opinion  appears  to  be  in  favour  of  ascribing  to  both  functions 
some  share  in  the  production  of  fatal  results.  At  any  rate,  it  is  admitted  on 
all  hands  that  the  depression  in  the  respiration,  even  if  it  is  not  absolutely 
coincident  with  the  circulatory  failure,  precedes  or  follows  it  so  closely  that, 
clinically,  it  is  almost  impossible  to  distinguish  between  the  two  effects,  and, 
therefore,  the  line  of  treatment  must  be  such  as  will  give  relief  in  both 
directions. 

Simple  syncope  appears  to  be  an  accident  to  which  patients  are 
occasionally  liable  in  the  very  earliest  stages  of  the  inhalation.  Some  such 
cases  are  undoubtedly  due  to  mere  fright,  and  can  hardly  be  ascribed  to 
the  toxic  effects  of  the  anaesthetic;  but,  on  the  other  hand,  many  cases 
are  on  record  in  which  no  such  dread  of  the  operation  existed,  but  where, 
nevertheless,  the  patient,  often  a  strong  healthy  adult,  has  suddenly  suc- 
cumbed after  inhaling  the  anaesthetic  for  a  few  minutes,  when  apparently 
unconscious,  and  passing  into  the  third  stage  (see  p.  94). 

In  origin,  respiratory  troubles  may  be  spasmodic,  asphyxial,  or 
due  to  the  toxic  effects  of  the  drug  upon  the  central  nervous  system. 
Spasm  of  the  glottis  may  occur  with  any  anaesthetic,  but  especially  with 
ether  when  the  vapour  is  too  suddenly  applied,  or  increased  in  strength 
too  rapidly  ;  the  treatment,  namely,  withdrawal  or  diminution  in  strength 
of  the  vapour,  is  obvious,  and  no  further  reference  need  be  made  to  it 
here.  The  irritation  of  the  ether  vapour  may  sometimes  cause  a  good 
deal  of  coughing,  and  if  this  does  not  subside  in  the  course  of  a  few 
minutes,  the  inhalation  of  a  few  drops  (10-20)  of  chloroform  will  often 
have  a  good  effect,  and  the  ether  inhaler  can  subsequently  be  re-applied. 
Asphyxial  symptoms  are  usually  associated  with  marked  lividity  and 
gasping  for  breath,  and  may  be  due  to  a  variety  of  causes,  such  as 
the  presence  of  foreign  bodies  (false  teeth,  detached  nasal  polypi,  etc.), 
to  excessive  flow  of  mucus,  to  blood,  to  extraneous  pressure  upon  the 
trachea,  to  falling  back  of  the  tongue  over  the  glottis  (sometimes  termed 
"  swallowing  the  tongue  "),  etc.,  etc.  Under  this  head,  too,  may  be  included 
those  cases  described  by  Lord  Lister,  in  which  the  soft  structures  at  the 
back  of  the  throat  fall  together  like  curtains  in  front  of  the  glottis. 

Respiratory  paralysis. — Of  course,  under  the  above  circumstances, 
whether  syncopal  or  asphyxial,  the  breathing  tends  to  fail ;  but  when  we 
speak  of  "failure  of  breathing"  under  anaesthetics,  and  especially  under 
chloroform,  what  is  usually  meant  is  the  failure  due  to  an  overdose.  The 
nervous  system  becoming  paralysed,  the  medullary  centres  cease  to  act, 


DIFFICULTIES   AND    DANGERS.  HI 

and  the  respiratory  movements,  becoming  feebler  and  feebler,  at  length 
stop  altogether.  The  ashy-grey  pallor  and  imperceptible  pulse,  the  entire 
cessation  of  breathing,  the  complete  relaxation  of  the  tissues,  extending 
sometimes  even  to  the  sphincters,  the  widely  dilated  pupils,  the  general 
aspect  of  the  patient,  not  unlike  the  fades  hippocratica  of  actual  death, 
are  all  very  characteristic,  and  in  fact  may  almost  be  said  to  be  patho- 
gnomonic  of  chloroform  poisoning;  sometimes,  the  respiratory  failure  is 
almost  lightning-like  in  rapidity,  but  more  often  it  is  gradual  and  insidious 
in  onset. 

As  is  well  known,  the  clinical  signs  and  symptoms  of  respiratory 
paralysis  closely  resemble,  and  are  frequently  associated  and  coincident 
with  those  due  to  syncope,  and,  on  the  other  hand,  obstruction  to 
the  breathing  sooner  or  later  leads  to  cardiac  failure.  In  practice,  it 
is  often  impossible  to  decide  whether  the  respiratory  or  the  cardio- 
vascular system  was  first  affected,  but  it  is  of  the  utmost  importance 
that  the  administrator  should  be  able  to  appreciate  the  fact,  that  certain 
signs  and  symptoms  are  indicative  of  approaching  danger  from  their  very 
commencement.  Such  early  recognition  of  symptoms  is  only  possible 
when  the  administrator  is  unceasingly  vigilant,  and  single-minded  in  his 
attention  to  his  duties,  and  the  obvious  advantage  is,  that  when  thus 
recognized  the  mere  withdrawal  of  the  anaesthetic  often  suffices  to  correct 
the  error,  without  subjecting  the  patient  to  any  additional  risk. 

It  is  to  the  respiratory  and  the  circulatory  systems,  and  especially  the 
former,  that  the  greatest  attention  should  be  devoted,  and  the  slightest 
alteration  in  either  one  or  the  other  should  be  carefully  noted  and  watched. 
If  this  be  done,  it  will  soon  be  seen  that  signs  of  danger  may  very 
readily  be  grouped  under  three  heads,  namely, 

(1)  Symptoms   in   which   cardiac   failure   or   syncope   is   the   prominent 

feature.  (Pallor,  pulse  gradually  becoming  imperceptible ;  pupil 
slowly  dilating ;  respirations  unaltered  at  first,  but  gradually  failing, 
though  seldom  abolished  completely.)  Generally  to  be  looked  for 
in  the  earlier  stages  of  anaesthesia ;  often  the  precursor  of  sick- 
ness. As  a  rule,  easily  recoverable. 

(2)  Symptoms  in  which   the   respiratory  failure  is  the  most  prominent 

feature.  (Respirations  early  affected,  feeble,  and  shallow  ;  pallor, 
often  of  the  ashy-grey  type ;  pulse  fairly  good  at  first,  but  slowly 
failing ;  pupils  quickly  dilating.)  A  condition  of  the  middle  and 
late  stages,  and  tending  to  merge  into 

(3)  Simultaneous  or  almost  simultaneous,  sudden,   and  complete  cessa- 

tion of  both  circulation  and  respiration,  with  facies  hippocratica, 
suddenly  and  widely  dilated  pupils.  May  occur  early  (syncope) 
or  late  (toxic  overdose).  A  very  serious  condition ;  when  fully 
developed  in  the  earlier  stages  of  anaesthesia,  it  is  doubtful  if 
recovery  is  possible. 


112  ANESTHETICS. 

Treatment. — Reference  has  already  been  made  (see  p.  95)  to  the  treat- 
ment to  be  adopted  when,  in  ether  anaesthesia,  the  muco-salivary  secretion 
becomes  excessive,  and  to  the  treatment  of  spasm  of  the  glottis.  The 
treatment  of  other  forms  of  gross  asphyxia  is  so  perfectly  obvious,  that 
it  may  be  dismissed  in  a  very  few  words.  If,  with  a  patient  sitting  up,  as 
for  nitrous  oxide  anaesthesia,  blood  or  a  foreign  body,  such  as  a  tooth, 
slips  back  into  the  larynx,  the  body  of  the  patient  should  be  bent  sharply 
forward  so  as  to  bring  the  head  over  the  knees ;  coughing  should  be 
encouraged  by  smartly  pairing  the  back,  and  by  passing  the  finger  into 
the  throat  to  irritate  the  vocal  cords.  This  latter  manoeuvre  may  reveal 
the  presence  of  the  foreign  body  itself,  and  an  attempt  may  be  made  to 
remove  it  by  means  of  the  laryngeal  forceps  (Fig.  34) ;  if  this  attempt  do 


FIG.  34. — LARYNGEAL  FORCEPS. 

not  succeed,  the  advisability  of  performing  tracheotomy,  or  even  better, 
laryngotomy,  must  be  considered.  Of  course,  in  many  cases,  this  operation 
would  be  performed  by  the  operating  surgeon,  but  the  administrator  should 
always  be  provided  with  suitable  instruments,  for  occasion  may  arise,  e.g.  in 
dental  work,  in  which  they  may  be  urgently  called  for  and  when  the 
anaesthetist  may  himself  have  to  operate.  In  any  event,  the  responsibility 
rests  with  the  anaesthetist. 

In  respect  to  the  other  symptoms  mentioned  on  p.  in,  it  must  be 
borne  in  mind  that,  although  in  some  instances  their  development  is 
almost  unavoidable,  yet  in  many  if  not  in  the  majority  of  cases  in  which 
they  are  very  pronounced,  they  can  be  traced  to  some  error  of  omission 
or  commission  on  the  part  of  the  anaesthetist.  It  may  not,  therefore, 
be  out  of  place  to  recapitulate  what  may  be  termed  the  prophylactic 
treatment  in  respect  to  these  symptoms,  viz., 

(a)  Take   care   to   remove   beforehand  anything  that  may  obstruct  the 
breathing,   or   that   may   fall   into   the   throat   when   the   parts   are   relaxed 
(see  p.  84). 

(b)  Excepting   in   the  case   of  nitrous  oxide,  always  induce  anaesthesia 
gradually ;  this  does  not  of  necessity  mean  slowly,  but  rather  the  graduation 


DIFFICULTIES   AND    DANGERS.  113 

of  strength  of  the  vapour,  not  increasing  the  strength  beyond  that  which 
can  be  readily  borne. 

(<:)  The  administrator  should  devote  the  whole  of  his  attention  to  the 
administration.  He  should  not  be  called  upon  to  hold  instruments,  or 
otherwise  assist  the  surgeon,  or  even  interest  himself  about  the  operation. 

(</)  As  soon  as  sufficiently  relaxed,  the  head  must  be  turned  to  one 
side,  so  as  to  permit  the  mucus  to  flow  out  of  the  mouth  and  prevent  the 
tongue  falling  backwards. 

(e)  The  respiration  must  be  watched  with  particular  care,  the  hand 
being  occasionally  held  in  front  of  the  nose  and  mouth  to  test  the  force 
of  the  breathing.  The  movements  of  the  chest  and  abdomen  are  not  to 
be  relied  upon,  as  they  may  be  altogether  out  of  proportion  to  the  amount 
of  air  actually  entering  the  lungs.  Nor  is  the  sound  of  the  breathing  to 
be  depended  upon ;  it  may  be  largely  due  to  mucus,  or  to  buccal  or 
palatine  stertor.  In  my  opinion,  too,  mechanical  indicators  in  the  shape 
of  feathers,  etc.,  are  apt  to  be  fallacious.  They  induce  a  false  sense  of 
security,  as  they  do  not  distinguish  between  a  very  light  and  a  moderately 
forcible  expiration.  At  the  same  time  the  circulation,  as  indicated  by  the 
colour  of  the  face  and  ears,  should  be  watched,  and  the  pupil  observed. 

(/)  If  in  doubt  as  to  the  exact  significance  of  any  particular  or  peculiar 
symptom  or  change,  it  is  safer  to  allow  the  patient  to  come  round  rather 
than  press  the  anaesthetic. 

Active  Treatment. — If,  however,  any  of  the  conditions  indicated  on 
p.  in  have  developed,  the  following  routine  treatment  should  be  adopted. 
It  is  of  importance  that  the  exact  order  of  procedure  be  observed ;  that 
each  step  be  carried  out  deliberately  and  completely,  without  flurry ;  that 
a  wait  of  at  least  a  few  seconds  be  made  between  each  movement,  to  be 
sure  of  its  effect,  and,  in  extreme  cases,  that  treatment  be  persevered  in  for 
some  time,  even  although  apparently  hopeless. 

(1)  Keep  the  head  turned  to  one  side,  but  do  not  otherwise  alter  the 
position  of  the  patient.     Withdraw  the  anaesthetic.      Extend  the  head  upon 
the  trunk  by  pressing  backwards  upon  the  forehead  ;  release  the  base  of  the 
tongue   by  forcible   pressure   upon   the  lower  jaw  at  the  angles,   so   as  to 
protrude  the  lower  incisor  teeth  beyond  the  upper,  or  by  pulling  forward  the 
chin  so  as  to  raise  the  hyoid  bone  and  larynx.     In  the  very  earliest  stages 
of  respiratory  embarrassment,  often  nothing  more  than  this  is  required.     If 
the  breathing  be  not  restored  by  these  means  the  next  step  is, 

(2)  Open  the  mouth,  by  means  of  the  gag  (Fig.  35),  if  necessary,  seize 
the  tip  of  the  tongue  in  the  forceps  (Fig.  36),  and  pull  the  tongue  forcibly 
forwards.      This  does   not  move  forward  the   base  of  the  tongue  to  any 
appreciable   extent,    but   probably   it   mainly  acts  reflexly,    and   causes  the 
retraction  of  the  soft  tissues  in  front  of  the  glottis,  and   is,  therefore,   of 
particular  service  in  the  condition  described  by  Lord  Lister  (see  p.   103). 

(3)  Should  the  above  manoeuvres  have  no  effect,  the  next  proceeding  is 
to  explore  and  clear  out  the  air-way.     The  finger  is  passed  to  the  back 

H 


114 


ANESTHETICS. 


of  the  throat,  and  used  as  a  hook  to  draw  forward  the  epiglottis  and  base 
of  the  tongue,  and  this  has  often  a  very  marked  effect,  and  should  on  no 
account  be  neglected.  At  the  same  time,  anything  in  the  shape  of  a  foreign 
body  can  be  felt  for,  and,  if  found,  attempts  may  be  made  to  remove  it 
with  the  finger,  or  by  means  of  the  laryngeal  forceps  (Fig.  34).  The  throat 
must  be  sponged  to  get  rid  of  the  mucus  and  blood,  and,  if  this  be  excessive, 
the  patient  may  very  gently  be  turned  on  one  side. 


FIG.  35. — FERGUSON'S  MOUTH  GAG.     The  toothplates  must  be  protected  with  pieces 
of  rubber  tubing. 


FIG.  36. — TONGUE  FORCEPS. 

If  a  foreign  body  or  definite  obstruction  can  be  felt,  but  cannot  be 
removed  with  the  finger  or  by  means  of  the  forceps,  and  if  the  asphyxia  is 
becoming  more  intense,  the  question  of  tracheotomy  may  now  arise,  but 
mere  feeble  breathing,  without  definite  signs  of  obstruction,  is  no  indication 
for  opening  the  trachea. 

It  is  absolutely  essential  to  commence  with  the  above  three  proceedings 
as  preliminary  to  anything  else  that  may  be  done ;  it  is  useless  to  attempt 
to  force  air  into  the  chest,  by  artificial  respiration  or  other  means,  unless  we 
first  assure  ourselves  that  the  air-passages  are  clear.  Violent  movement  of 
the  patient  at  this  early  stage  may  have  no  other  result  than  that  of  shaking 
the  last  flicker  of  life  out  of  his  body;  do  not,  therefore,  be  over  hasty. 
If,  after  waiting  for  ten  or  fifteen  seconds,  we  get  no  response  to  our  efforts, 
the  next  steps  are, 

(4)  Make  two  or  three  momentary  pressures  upon  the  sternum ;  it  may 
be  that  it  is  merely  the  rhythm  of  respiration  which  is  in  abeyance. 

(5)  Invert  the  patient. — Children  may  be  held  up  by  the  heels ;    with 
adults,  an  assistant  standing  on  the  table  may  hold  up  the  legs,  and  the 
body  of  the  patient  may  be  pulled  upwards,  so  that  the  head  hangs  over 


DIFFICULTIES   AND    DANGERS.  115 

the  end  of  the  bed.  One  theory  explaining  the  action  of  this  proceeding 
is,  that  it  empties  the  blood  from  the  abdominal  viscera  towards  the  heart 
and  brain.  The  effect,  therefore,  is  one  of  mechanical  stimulus,  and,  if  this 
be  so,  one  can  understand  the  advice  which  is  given  not  to  prolong  the 
position  for  more  than  a  few  minutes  at  a  time. 

(6)  In  adults,  even  while  inversion  is  being  tried,  artificial  respiration 
may    be    started,    commencing    slowly    and    gradually.      The    well-known 
Sylvester's  method  is  the  one  usually  adopted.     Standing  at  the  patient's 
head,   a  firm  grasp  is  taken  just  below  the  elbows,   and  the  arms  brought 
outwards   and   upwards  with  a  rotatory  movement,  some   force  being   used 
to  cause  the  forearms  to  cross  above  the  head ;  expiration  is  brought  about 
by  reversing  the  movement,  pressing  the  arms  firmly  against  the  chest  walls 
so   that    the    forearms    cross    over    the    front   of  the   chest.      In    Howard's 
method,    which    is    a    most    valuable    adjunct    to   the   above,    the   surgeon 
kneels  astride  of  the  patient,  places  his  outspread  palms  over  the  margins 
of  the   ribs,  pushes  up  the  abdominal  viscera  against  the  diaphragm,  and 
then  allows  them  to  fall  away,  and  so  alternately  diminishes  and  increases 
the  capacity  of  the  thorax.     In  infants,  too,  it  is  useful  to  remember  that 
pressure   on    the   abdomen  upwards    towards   the  diaphragm,    or  upon   the 
costo-diaphragmatic  margin  is  often  more  effectual  than  anything  else.     When 
possible,   these  two  methods  should  be  carried  out  simultaneously,   but  in 
any  event,    the    movements  should   not   be   made  roughly  or  too  rapidly ; 
about  sixteen  or  seventeen  to  the  minute  is  ample. 

It  has  been  urged  against  these  two  plans  of  artificial  respiration,  that 
there  is  a  danger  of  pumping  up  the  contents  of  the  stomach  into  the 
pharynx,  and  so  practically  drowning  the  patient,  and  the  Marshall  Hall 
method  of  turning  the  patient  alternately  upon  his  face  and  side  has  been 
suggested  as  an  alternative.  But  the  objection  can  hardly  apply  unless 
the  movements  have  been  made  altogether  too  violently  and  too  quickly, 
and  mention  is  only  made  of  it  here  in  order  to  emphasize  these  points, 
and  to  put  the  administrator  on  his  guard. 

In  the  majority  of  cases,  if  the  breathing  has  shown  no  signs  of  re- 
commencement after  artificial  respiration  has  been  continued  for  five  or  ten 
minutes,  the  prognosis  is  exceedingly  grave;  but  it  is  not  altogether  hope- 
less, so  that,  while  still  persevering  with  the  artificial  respirations,  some  of 
the  following  plans  should  be  adopted  by  the  assistants.  It  must  be  quite 
understood,  however,  that  these  plans  are  to  be  carried  out  concurrently 
with  the  artificial  respiration,  and  on  no  account  is  the  latter  to  be  super- 
seded by  them. 

(7)  Cold   affusions   in  the  shape  of  douches  or  flipping  the  chest  with 
wet  towels.     Alternate  very  hot  and  cold  sponges  to  the  perineum. 

(8)  Inhalation  of  nitrite  of  amyl  to  alter  the  distribution  of  the  intra- 
vascular  tension.     Strong  ammonia  held  to  the  nose. 

(9)  Electricity. — Either    the    interrupted    (Faradic)    or    the    continuous 
current  may  be  used.     One  pole  is  applied  to  some  neutral  point,  e.g.  the 


Il6  AX/ESTHETICS. 

nape  of  the  neck,  and  the  other  pole  is  pressed  over  the  cardiac  area, 
along  the  costo-diaphragmatic  margin,  or  along  the  course  of  the  phrenic 
and  pneumogastric  nerves  in  the  neck,  the  current  being  alternately  made 
and  broken. 

(10)  Hypodermic  injections  of  ether  or  brandy  (mxxx.)  are  usually 
given,  but  the  proceeding  is  a  little  illogical.  The  patient  is  already  suffer- 
ing from  a  form  of  alcoholic  poisoning,  and,  further,  the  circulation  is  too 
depressed  to  hope  for  absorption.  For  this  latter  reason,  too,  the  hypo- 
dermic injection  of  drugs,  such  as  digitaline,  is  hopeless  at  this  stage. 

(n)  The  intra- venous  injection  of  normal  salt  solution,  or  rectal  injec- 
tions of  the  same,  appear  to  be  more  rational.  By  altering  the  blood 
pressure  they  might  possibly  stimulate  the  circulation. 

(12)  As  almost  a  last  resource,  acu-puncture  or  galvano-puncture  of 
the  heart  itself  has  been  recommended.  It  has  even  been  suggested 
that  by  making  a  small  incision  along  the  margins  of  the  left  ribs,  the 
ringers  of  the  hand  can  be  passed  in,  and  direct  pressure  applied  to  the 
heart.  I  have  no  personal  experience  of  these  measures,  but  it  appears  to 
me  that  acu-puncture  and  galvano-puncture  not  only  waste  valuable  time, 
but  are  more  likely  to  do  harm  than  good.  The  plan  of  directly  pressing 
on  the  heart  seems  to  be  better  justified,  theoretically,  but  I  am  not 
aware  that  it  has  ever  been  put  to  practical  proof. 

Supposing  that  no  response  has  been  obtained  to  these  efforts,  the 
artificial  respiration  should  be  persevered  in  for  at  least  half-an-hour, 
and  of  course,  if  the  slightest  attempt  at  natural  breathing  be  made,  a 
longer  time  should  be  given  to  the  work.  Even  after  a  fairly  regular, 
though  feeble  respiratory  rhythm  has  been  re-established,  the  greatest  care 
should  be  taken  in  moving  the  patient,  as  relapses  are  very  apt  to  occur ; 
he  should  not,  therefore,  be  left  for  some  hours,  and  should  be  kept  very 
warm. 

After-Treatment. 

In  conclusion,  a  few  words  may  be  said  as  to  the  after-treatment  of 
patients  recovering  from  an  anaesthetic,  as  this  is  a  point  upon  which  the 
anaesthetist  is  often  consulted.  Practically,  no  after-treatment  is  required 
for  nitrous  oxide;  the  following  remarks  are  intended  only  for  the  major 
anaesthetics. 

In  dressing  a  case  after  operation,  care  should  be  exercised  that  the 
bandages,  etc.,  do  not  impede  the  breathing.  This  is  particularly  necessary 
in  operations  about  the  head  and  neck,  and  it  comes  within  the  province 
of  the  administrator  to  see  that  no  trouble  arises  from  this  cause.  In 
these  cases  the  bandages  should  be  applied  fairly  firm,  while  the  neck  is 
fully  extended ;  the  pressure  will  not  then  be  too  great  when  the  neck  is 
restored  to  position. 

In  ordinary  cases,  the  patient  may  be  put  back  to  a  warm  bed  before 
he  completely  recovers  consciousness.  In  making  the  transfer,  however, 


AFTER-TREATMENT. 


117 


care  should  be  taken  not  to  jolt  him,  and  especially  not  to  elevate  the 
head  and  chest;  in  going  upstairs,  therefore,  he  should  be  carried  on  a 
stretcher,  feet  first,  with  his  head  down.  The  room  should  be  of  a  tem- 
perature of  about  65°-7o°  F.,  and  the  bed  carefully  screened  from  draughts. 
If  ether  has  been  employed,  and  perhaps  in  all  cases,  it  is  better,  if  the 
surgeon  will  permit,  that  the  patient  be  turned  upon  the  right  side;  this 
facilitates  the  escape  of  mucus,  and  I  think  lessens  the  sickness.  The 
nurse  should  be  warned  that  if  sickness  occur  the  patient  is  not  to  sit  up, 
but  to  be  turned  on  his  side,  and,  if  need  be,  the  jaw  must  be  pushed 
forward  to  facilitate  the  escape  of  the  vomited  matter. 

The  anaesthetist  should  assure  himself  that  his  patient  is  on  the  high 
road  to  recovery  before  he  leaves  the  patient's  side,  but  on  the  other 
hand,  natural  sleep  is  to  be  encouraged;  if,  when  taken  at  intervals  of 
two  or  three  minutes,  the  pulse  and  respiration  are  found  to  be  good 
and  improving,  it  may  fairly  be  assumed  that,  as  far  as  the  anesthetic 
is  concerned,  the  patient  is  safe.  In  any  event,  whether  the  case  is  a 
severe  one  or  not,  the  patient  should  always  have  a  responsible  attendant 
at  his  bedside  for  an  hour  or  two  after  the  operation  has  been  completed. 
Sickness. — As  soon  as  he  is  sufficiently  conscious  to  be  able  to  do 
so,  the  patient  should  be  encouraged  to  frequently  rinse  out  his  mouth 
and  throat  with  warm  water.  If  it  occurs  early,  in  the  semi-unconscious 
condition,  retching  and  vomiting  are  less  distressing  to  the  patient  than  at 
first  sight  appears ;  when  he  becomes  fully  conscious  he  seldom  retains 
any  recollection  of  his  previous  misery.  Nevertheless,  attempts  should  be 
made  to  ameliorate  his  condition.  Sips  of  water  as  hot  as  can  be  borne, 
or  even  full  draughts  of  half  a  tumblerful,  are  often  successful ;  strong,  hot, 
black  coffee  is  good  in  some  cases;  15  to  20  grains  of  bicarbonate  of  soda 
in  a  tumblerful  of  hot  water  is  good  in  others  ;  ice  to  suck  is  the  routine 
treatment,  and  is  very  comforting  to  the  patient ;  strychnine  in  5m.  doses 
of  the  liquor  by  the  mouth  or  hypodermically,  has  been  recommended, 
and  in  the  more  troublesome  cases  morphine  may  be  called  for,  but  in 
the  majority  of  instances  time  alone  is  all  that  can  be  depended  upon. 

In  cases  involving  severe  "surgical  shock,"  additional  care  is  called 
for.  In  such  cases,  the  amount  of  the  anaesthetic  used  in  the  latter  stages 
may,  with  advantage,  be  very  much  diminished,  and  strychnine  hypoder- 
mically may  be  given  freely  (see  p.  84).  It  is  in  these  cases,  too,  that 
the  hypodermic  injection  of  brandy  or  ether  may  be  of  some  possible  value, 
but  a  nutrient  enema  of  hot  fluids  is  probably  better  (see  p.  83).  Such 
patients  should  not  be  put  back  to  bed  too  soon,  but  be  kept  on  the 
operating  table,  which  should  be  raised  some  four  or  five  inches  from  the 
ground  at  one  end  so  as  to  raise  the  patient's  legs.  Hot  water  bottles 
should  be  placed  all  round  the  body  and  extremities,  taking  particular  care 
whenever  hot  bottles  are  used,  that  they  are  thickly  covered  in  flannel ; 
patients,  when  anaesthetized^  are  very  apt  to  be  blistered  unless  the  bottles 
are  covered. 


Il8  ANAESTHETICS. 

If  the  shock  be  the  result  of  loss  of  blood,  it  may  be  advisable  to 
give  an  intra-venous  injection  of  normal  salt  solution,  or  rectal  injections 
of  salt  and  water  (see  Chap.  VI.),  but  probably  the  hot  nutrient  enemata 
recommended  above  is  more  efficacious. 

Diet. — No  food  should  be  given  by  the  mouth  for  at  least  three  or 
four  hours  after  an  anaesthetic  has  been  administered,  (in  the  case  of 
nitrous  oxide,  however,  an  hour's  abstinence  will  suffice),  and  a  further 
wait  of  two  or  three  hours  should  be  made  unless  the  patient  express  a 
desire  for  food,  or  if  the  sickness  be  very  persistent.  In  cases  of  collapse, 
marked  emaciation  and  feebleness,  etc.,  nutrient  enemata  should  be  given 
every  two  or  three  hours,  commencing  immediately  before  the  oper- 
ation, rather  than  run  any  risk  of  irritating  the  stomach.  The  first  food 
by  the  mouth  should  take  the  form  of  broth,  beef-tea,  or  soup,  rather  than 
milk,  which  is  apt  to  form  a  hard  indigestible  curd  which  may  irritate  the 
stomach  in  its  catarrhal  condition.  When  the  first  food  has  been  retained, 
the  patient  may  return  by  degrees  to  the  ordinary  diet,  as  far  at  any  rate 
as  the  anaesthetic  is  concerned. 

Delirium  and  excitement,  when  they  occur,  must  be  gently  restrained,  but 
the  patient  must  not  be  tied  down.  In  the  case  of  lunatics,  the  feeble- 
minded, and  even  those  with  a  previous  history  of  mental  disturbance, 
the  friends  should  be  warned  that  a  recrudescence  of  the  mental  trouble 
occasionally  occurs  after  the  administration  of  any  anaesthetic. 


LOCAL  ANESTHESIA. 
Preliminary   Observations. 

Whether  pain  be  the  result  of  disease  or  be  caused  by  surgical  inter- 
ference, the  first  and  most  natural  impulse  is  to  seek  relief  in  local  appli- 
cations; we  find,  therefore,  that  such  applications  have  been  in  vogue  from 
the  earliest  times.  The  use  of  inhalations  of  the  vapours  of  ether  and 
chloroform,  quickly  supplanted  the  less  certain  and  somewhat  empirical 
local  methods  formerly  employed,  and  it  is  only  during  the  last  ten  or 
fifteen  years  that  the  production  of  local  anesthesia  has  been  systematically 
studied ;  and  it  is  even  more  recently  that  any  attempts  have  been  made 
to  define  its  advantages  and  limitations.  It  is  to  Continental  and 
American  surgeons  that  we  are  chiefly  indebted  for  our  knowledge  of  the 
subject ;  in  this  country,  the  plans  advocated  have  met  with  but  a  limited 
amount  of  support. 

Advantages. — It  is  claimed  for  local  anaesthetics  that  no  previous 
preparation  of  the  patient  is  required ;  that  they  are  on  the  whole  more 
portable  and  more  readily  available  than  most  general  anaesthetics ;  that 
they  are  easy  of  application  ;  that  it  is  sometimes  of  advantage  that  the 
patient  should  be  able  to  assist  the  surgeon  in  his  manipulations,  e.g.  by 


LOCAL  ANESTHESIA.  119 

forcing  down  a  hernia ;  that  they  can  often  be  used  when  a  general 
anaesthetic  would  be  inadvisable,  e.g.  in  cases  of  collapse,  and  in  the  very 
emaciated  and  feeble ;  that,  on  the  whole,  some  of  the  methods,  e.g.  freezing, 
are  safer,  and  are  less  likely  to  be  followed  by  disagreeable  after-effects. 
Against  this  list  of  advantages,  must  be  balanced  the  rather  more  weighty 
objections  that  they  are  uncertain  in  action,  and  cannot  always  be  relied 
upon  to  produce  the  desired  effect,  so  that  it  is  usually  necessary  to  hold 
a  general  anaesthetic  in  reserve,  to  be  used  if  required ;  the  element  of 
shock  is  seldom  abolished  or  even  diminished ;  the  tissues  are  unrelaxed  ; 
the  appearance  of  the  surrounding  parts  is  so  altered  by  the  oedema,  etc., 
that  dissection  becomes  almost  impossible,  and  it  is  open  to  question  whether 
the  healing  of  the  wound  be  not  retarded ;  the  fear  of  the  operation,  and  the 
very  disturbing  element  of  the  sight  of  instruments,  blood,  etc.,  has  always 
to  be  reckoned  with,  even  in  the  apparently  robust  and  firm-minded. 

Cases  suitable. — A  careful  study  of  the  lists  which  have  been 
published,  of  operations  which  can  be  and  have  been  performed  by  the 
aid  of  local  anaesthetics,  and  having  regard  to  the  attendant  circumstances 
of  the  cases  recorded,  leads  one  to  the  conclusion  that,  as  far  as  our 
present  knowledge  goes,  the  only  occasions  on  which  local  can  claim  any 
real  advantage  over  general  anaesthesia  are  as  follows,  viz., 

(1)  In   very   brief   cases   where   no    dissection    is   required,    e.g.    simple 

puncture  or  incision  of  small  abscesses,  and  when  nitrous  oxide 
is  not  available  or  is  objected  to. 

(2)  In  the  aged,  whose  whole  nervous  system  and  tissues  generally  are 

often  less  sensitive  than  in  younger  people. 

(3)  In  those  who   are   much   collapsed,   or  feeble   and   emaciated,  and 

in  whom,  therefore,  there  is  reason  to  fear  the  effect  of  a  general 
anaesthetic  in  depressing  the  already  reduced  vitality. 

(4)  In  ophthalmic  surgery,  and  in  some  operations  involving  the  super- 

ficial mucous  membranes,  e.g.  nasal  polypi. 

Although  special  preparation  of  the  patient  is  not  so  imperatively  called 
for  as  with  general  anaesthesia,  it  is,  nevertheless,  of  advantage,  that  the 
general  condition  should  be  improved  by  careful  regulation  of  the  diet,  etc., 
for  a  few  days  beforehand.  Purging  or  starving  are  not,  of  course,  at  all 
necessary ;  in  fact,  it  is  better  that  the  patient  should  have  a  cup  of  hot 
broth  or  beef-tea  immediately  before  the  operation;  this  may  counteract 
any  tendency  to  syncope,  and  for  the  same  reason  a  little  stimulant  is 
not  objectionable.  Whenever  possible,  the  patient  should  be  recumbent. 

Methods. — The  local  methods  most  in  use  at  the  present  time  may 
be  considered  under  the  following  heads,  viz.:  (i)  Freezing;  (2)  Drugs; 
(3)  Infiltration. 

Freezing. 

The  anaesthetic  properties  of  intense  cold  have  long  been  made  use 
of  in  practical  surgery.  In  operative  work,  the  cases  most  suitable  for 


120  AN/ESTHETICS. 

freezing  are  those  which  do  not  involve  any  large  area  of  surface,  but 
which  only  require  a  short,  simple  incision  or  puncture,  e.g.  opening 
a  superficial  abscess.  The  method  is  open  to  the  special  objections  that 
the  tissues  are  apt  to  become  so  hard,  that  it  is  sometimes  difficult  to  cut 
through  them,  so  no  dissecting  operation  can  be  carried  out;  and  that  the 
process  of  thawing  is  often  accompanied  by  much  pain,  the  healing  is 
retarded,  and  the  tissues  are  liable  to  slough. 

A  simple  plan  is  to  employ  a  mixture  of  two  parts  of  pounded  ice  to 
one  of  salt.  This  is  placed  in  an  india-rubber  bag,  and  laid  upon  the  part 
to  be  operated  upon  until  the  latter  assumes  a  dead-white  colour,  and  is 
frozen  hard.  This  plan  is  hardly  to  be  recommended  in  any  case;  too 
large  an  area  is  frozen,  and  there  is  a  great  tendency  for  the  parts  to 
slough. 

The  late  Sir  Benjamin  Ward  Richardson  was  a  great  advocate  for 
freezing  anaesthesia,  and  introduced  the  ether  spray  (Fig.  37).  The  ether 
used  for  this  purpose  is  the  methylated  ether,  and  is  often  known  as 


a 


FIG.  38.—  METAL  BOTTLE  CONTAINING  .AN.«STILE. 
The  tap  <*  being  unscrewed,  the  heat  of  the  hand  forces 
FIG.  37. — ETHER  SPRAY.  a  minute  stream  of  liquid  out  of  the  orifice. 

"anaesthetic  ether";  it  should  have  a  spec.  grav.  of  717  or  under.  The 
nozzle  of  the  spray  is  held  a  few  inches  away  from  the  part  to  be  frozen, 
so  that  the  liquid  falls  in  a  fine  shower  upon  the  surface  ;  in  about  two 
minutes  the  skin  becomes  hard  and  white,  and  the  incision  may  then  be 
made. 

A  very  convenient  adaptation  of  this  principle  of  freezing  by  evaporation 
is  seen  in  the  use  of  tubes  containing  ethyl  chloride,  anaestile,  and  other 
fluids  of  low  boiling  point  (Fig.  38).  In  these  tubes,  the  heat  of  the  hand 
suffices  to  drive  a  stream  of  the  liquid  through  a  minute  hole  in  the 
nozzle,  and  at  a  distance  of  a  few  inches  the  jet  is  broken  up  into  a  fine 
spray,  and  the  part  upon  which  this  spray  falls  is  quickly  frozen.  These 
substances  appear  to  be  rather  more  rapid  in  action  than  pure  ether,  to 


LOCAL  ANESTHESIA.  121 

produce  a  sufficient,  but  not  too  great  a  fall  in  temperature,  and,  therefore, 
the  hardness  of  the  skin,  and  the  after-smarting  are  less  obvious  objections 
than  when  simple  freezing  or  the  ether  spray  are  employed.  In  using 
these  tubes,  care  must  be  taken  that  the  nozzle  is  held  far  enough  off  the 
part  to  enable  the  stream  of  fluid  to  fall  in  a  fine  shower  upon  the  surface, 
otherwise,  free  evaporation  does  not  take  place,  and  the  freezing  is  much 
delayed. 

Drugs. 

Many  drugs,  partly  by  their  direct  action  upon  the  nerve  endings,  partly 
by  the  pressure  of  the  fluid  injected,  partly  by  interfering  with  the  blood 
supply  of  the  part,  have  an  anaesthetic  action  upon  the  tissues  in  the  imme- 
diate vicinity  of  their  point  of  application.  For  instance,  an  incision  made 
into  a  tissue  upon  which  pure  carbolic  acid,  or  even  a  solution  of  1-20,  has 
been  painted,  will  hardly  be  felt,  but  this  plan  is  not  to  be  recommended, 
The  drug  generally  employed  nowadays  is  cocaine.  This  is  the  crystal- 
line, active  principle  of  the  leaves  of  the  coca  plant  (erythroxylon  coca), 
and  its  chemical  constitution  is  represented  by  the  formula  C17H21NO4. 
The  alkaloid  itself  is  nearly  insoluble  in  water,  but  the  hydrochlorate  is 
freely  soluble,  and  is  the  form  in  which  the  substance  is  generally  used. 
Solutions  of  this  salt  are  particularly  prone  to  decomposition,  and  numerous 
forms  of  infective  bacteria  frequently  appear.  To  a  considerable  extent, 
this  is  prevented  if  5  per  cent,  of  salicylic  acid  be  added  to  the  solution. 

When  first  introduced  into  surgical  practice,  the  use  of  5  per  cent,  and 
10  per  cent,  solutions  was  advised,  and  these  are  about  the  strengths  still 
usually  employed  in  this  country.  On  the  Continent  and  in  America, 
however,  where,  as  already  mentioned,  the  subject  of  local  anaesthesia  has 
received  much  attention,  it  has  lately  been  proposed  to  use  rather  larger 
quantities  of  much  weaker  strength  (i  or  2  per  cent.),  with  a  view  to 
avoiding  the  untoward  symptoms  which  frequently  occur  when  the  more 
potent  solutions  are  employed.  In  any  event,  not  more  than  from  | 
to  f  gr.  of  the  drug  itself  should  be  injected  hypodermically  at  a  single 
sitting. 

In  using  cocaine,  it  is  particularly  advisable  that,  whenever  possible, 
the  patient  should  be  recumbent,  and,  as  a  useful  precaution,  a  cup  of 
broth  or  beef-tea,  or  an  alcoholic  stimulant  may  be  given  beforehand. 

The  following  are  the  principal  plans  adopted,  viz., 

(1)  Instillation. — In  ophthalmic  surgery  a  few  drops  of  the  solution  are 

placed  in  the  eye,  and  the  instillation  is  repeated  at  intervals  of 
three  or  four  minutes,  until  a  sufficient  degree  of  anaesthesia  has 
been  obtained  ;  this  is  usually  after  the  lapse  of  from  five  to  ten 
minutes. 

(2)  Spray. — This   is   useful   in  operations   about  the   nose   and   larynx. 

A  convenient   form   of  spray-producer   is   shown   in  Fig.   39.      A 


122  ANESTHETICS. 

few  drops  are  sprayed  at  intervals  over  the  surface  to  be  operated 
upon,  as  with  instillations. 


FIG.  39.— COCAINE  SPRAY. 

(3)  Painted  on  the  surface,  e.g.  mucous  membranes,  etc.     Or  a  pledget 

of  cotton  wool  soaked  in  the  solution  may  be  allowed  to  remain 
for  a  few  minutes  in  contact  with  the  area  of  operation.  This 
latter  plan  is  useful  in  operations  about  the  anterior  nares  and 
aural  meatus,  but  mere  painting  on  the  unbroken  skin  is  of  but 
little  service. 

(4)  Hypodermically. — The  weaker  of  the  solutions  are  used  for  this  pur- 

pose, and  from  three  to  five  minims  are  injected  in  the  direction 
of  the  proposed  incision,  and  the  injection  is  repeated  once  or 
twice  at  different  angles,  so  as  to  infiltrate  the  surrounding 
tissues. 

Dangers. — Many  people  are  particularly  susceptible  to  the  action  of 
cocaine;  even  a  few  minims  sprayed  upon  the  throat  may  then  give  rise 
to  a  train  of  really  alarming  symptoms,  such  as  vertigo,  dryness  of  the 
mouth,  dilated  pupils,  cold  extremities,  palpitation,  slow  pulse  of  high 
tension,  restlessness,  delirium,  etc.  Should  such  symptoms  develop,  the 
patient  must  immediately  be  placed  recumbent,  hot  bottles  applied  to  the 
extremities,  stimulants  given,  and  other  precautions  taken  to  avoid  collapse. 
It  is  said  by  some  that  these  poisonous  effects  are  to  some  extent  pre- 
vented, if  antipyrine  be  added  to  the  solution.  A  very  good  formula  is  the 
following,  viz., 


Cocaine, 
Antipyrine,  - 
Sterilized  water, 


9     grains. 
75     grains. 


LOCAL  ANAESTHESIA.  123 

An  artificially  prepared  alkaloid,  closely  allied  to  cocaine,  has  recently 
been  introduced.  It  has  been  called  eucaine,  and  appears  likely  to  supplant 
cocaine  for  many  of  the  purposes  for  which  the  latter  is  used.  Solutions 
of  the  hydrochlorate  of  eucaine  are  less  liable  to  decomposition  than  salts 
of  cocaine,  and,  while  almost  equally  efficacious,  they  seem  to  be  far  less 
likely  to  give  rise  to  toxic  symptoms.  For  ophthalmic  surgery,  however, 
eucaine  does  not  appear  to  be  so  satisfactory,  as  it  sometimes  gives  rise  to 
conjunctival  irritation. 

Eucaine  should  be  used  in  the  same  way,  and  in  solutions  of  the  same 
strength  as  cocaine,  but  as  its  toxic  effects  are  only  about  two-thirds  that 
of  the  latter  drug,  it  may  be  administered  in  proportionately  greater 
quantities. 

Infiltration. 

In  1891  Dr.  C.  L.  Schleich  of  Berlin  introduced  quite  a  new  departure 
in  the  matter  of  local  anaesthetics.  After  a  series  of  carefully  planned 
and  elaborate  experiments,  Dr.  Schleich  found  that  it  was  possible  to 
produce  a  very  complete  degree  of  anaesthesia  if  the  tissues  were 
thoroughly  infiltrated  with  a  cold,  neutral,  salt  solution,  and  that  the  effect 
was  still  further  enhanced  by  the  addition  of  minute  quantities  of  certain 
drugs,  such  as  morphine,  cocaine,  etc. 

The  formulae  for  the  solutions  are  : — To  one  litre  or  quart  of  steri- 
lized water,  to  which  has  been  added  20  drops  of  a  5  p.c,  solution  of 
carbolic  acid,  add  : 

No.   i,  or  strongest,  solution. 

Cocaine  mur., 2'O    gm. 

Morph.  sulph.,  0^25  gm. 

Sod.  chlor.  (sterilized), 2-o    gm. 

No.  2,  or  medium,  solution. 

To  the  litre  as  above, 

Cocaine  mur.,  -         -         -         -  I'O    gm. 

Morph.  sulph., 0*25  gm. 

Sod.  chlor.  (sterilized),    -  ...  2'O    gm. 

No.  3,  or  weakest,  solution. 
To  the  litre  as  above, 

Cocaine  mur.,  .......     o'l    gm. 

Morph.  sulph., 0^05  gm. 

Soda  chlor.  (sterilized), 2-o    gm. 

As  much  as  25  c.c.  (6  dr.)  of  No.  i,  100  c.c.  (3  oz.)  of  No.  2,  and 
500  c.c.  (15  oz.)  of  No.  3,  may  be  considered  the  maximum  quantity 
of  these  fluids  to  be  used  for  the  average  adult.  No.  2  solution  is  used 
in  95  per  cent,  of  the  cases,  while  No.  i  is  used  in  highly  inflamed  and 
tender  parts,  and  No.  3  only  in  big  operations  when  more  than  5  3  is  likely 
to  be  required. 


I24 


ANESTHETICS. 


In  using  these  solutions,  great  stress  is  laid  upon  the  technique  of  the 
proceeding.  The  essence  of  the  process  consists  in  raising  a  series  of  small 
wheals  or  bubbles  under  and  around  the  area  of  operation ;  for  each 
succeeding  wheal,  the  point  of  the  injecting  syringe  is  inserted  within  the 
margin  of  that  which  immediately  precedes  it1 


FIG.  40. — ANAESTHESIA  BY  INFILTRATION  (Schleich).     Needle  introduced  at  some 
distance  from  the  area  to  be  operated  upon,  and  made  to  pierce  the  true  skin. 


FIG.  41. — ANESTHESIA  BY  INFILTRATION  (Schleich).     Showing  how  the  bubbles 
of  liquid  overlap,  and  are  made  to  surround  the  affected  area. 

Excellent  as  this  plan  has  no  doubt  proved  in  the  hands  of  Dr. 
Schleich  and  his  followers,  it  will  be  seen  at  once  that  it  does  not  over- 
come many  of  the  difficulties  and  objections  made  to  local  anaesthesia  in 
general,  under  the  head  of  "  Preliminary  Observations "  at  the  beginning 
of  this  section.  It  is  claimed  for  it  that,  as  the  process  can  be  repeated 
without  risk  as  often  as  may  be  required,  it  is  quite  possible  to  conduct 
an  elaborate  and  lengthy  operation  by  this  method ;  but,  on  the  other 
hand,  it  is  obviously  objectionable  to  break  off  an  operation  in  the  middle 
for  the  purpose  of  making  a  fresh  series  of  injections,  while  the  cedema 
produced  renders  any  operation  very  difficult,  and  dissection  almost  im- 
possible. 

1  For  Figs.  40  and  41,  illustrating  the  details  of  this  method,  we  are  indebted  to  the 
Medical  News  of  New   York. 


CHAPTER   VI. 

WOUNDS. 

MANAGEMENT  OF  OPERATIONS  AND  THE  TREATMENT  OF  THEIR  CHIEF 
IMMEDIATE  RISKS:  HEMORRHAGE,  SHOCK,  AND  SYNCOPE. 

THE  subject  of  wounds,  their  varieties,  complications  and  treatment,  is  one 
of  the  very  highest  importance.  Wounds  may  be  the  result  of  accident 
or  may  be  made  intentionally  by  the  surgeon,  and  between  the  two 
classes  there  are  important  differences.  They  may  be  divided  into  incised, 
contused,  lacerated,  gunshot,  or  poisoned  wounds,  and  those  caused  by 
heat  and  cold.  Certain  points  common  to  all  wounds,  such  as  the  questions 
of  pain,  of  shock,  and  of  bleeding,  and  the  risks  of  inflammation,  also 
require  to  be  studied.  Lastly,  various  septic  diseases  which  are  apt  to  occur 
in  connection  with  wounds,  such  as  traumatic  fever,  traumatic  delirium, 
septicaemia,  hectic  fever,  pyaemia,  tetanus,  and  erysipelas  have  to  be  taken 
into  account.  Before,  however,  proceeding  to  deal  with  them,  it  seems 
advisable  to  say  a  few  words  about  the  general  management  of  operations. 
Operations  may  be  divided  into  two  great  classes,  namely,  those  where 
the  condition  is  urgent  and  the  operation  must  be  carried  out  without 
delay,  and  those  where  some  time  may  be  allowed  to  elapse  after  an 
operation  has  been  decided  upon.  In  the  latter  case  various  preliminary 
steps  should  be  taken,  some  of  which  we  shall  briefly  indicate. 

PREPARATION   OF   PATIENT   FOR   OPERATION. 

In  the  first  place,  certain  points  in  the  way  of  preparation  of  the 
patient  should  be  attended  to.  Some  of  these  are  special  to  operations 
in  certain  regions,  and  will  be  mentioned  in  describing  particular  opera- 
tions :  such  are  the  cleansing  of  the  mouth  and  teeth  in  operations  on 
the  tongue,  etc.,  washing  out  the  stomach  in  gastrostomy  and  gastro- 
enterostomy,  emptying  the  lower  bowel  in  excision  of  the  rectum,  and 
so  on.  But,  apart  from  these  special  matters,  there  are  certain  points 
common  to  many  operations  which  will  be  considered  here. 

The  mental  attitude  of  the  patient  is  a  point  of  very  considerable 
importance,  especially  as  affecting  the  occurrence  of  shock  during  and  after 


126  WOUNDS. 

the  operation.  When  he  has  once  decided  to  undergo  an  operation,  the 
patient  should  be  encouraged  to  look  forward  to  a  successful  result ; 
nothing  is  worse  for  him  than  to  feel  that  he  is  going  to  succumb ;  shock 
certainly  seems  to  intervene  more  quickly  and  more  powerfully  under  such 
circumstances.  Hence,  although  the  patient  and  his  friends  should  be 
made  aware  of  the  real  danger  and  results  of  the  proposed  operation,  as 
soon  as  its  performance  has  been  decided  on  the  brightest  side  of  the 
picture  should  be  put  in  the  foreground  and  any  drawbacks  made  light  of. 

In  regard  to  feeding  before  an  operation,  there  is  no  object  in  inter- 
fering with  the  patient's  usual  diet  on  the  preceding  day,  but  it  is  well 
that  the  evening  meal  should  be  light  and  easily  digestible.  On  account 
of  the  anaesthetic,  food  should  not  be  given  by  the  mouth  later  than  three 
hours  before  the  operation,  and  if  this  is  to  be  performed  in  the  early 
morning  it  is  not  worth  while  waking  up  the  patient  for  a  meal.  If  he  be 
awake,  it  is  as  well  to  give  a  cup  of  strong  hot  beef-tea  or  Valentine's 
meat  juice  about  six  o'clock  in  the  morning  when  the  operation  is  to  be 
performed  about  nine.  When  the  operation  is  to  be  a  severe  one,  it  is 
also  advisable  to  give  a  nutrient  enema  half  an  hour  before  operation ; 
for  methods  of  preparation,  etc.,  see  p.  83. 

The  bowels  should  in  all  cases  be  well  cleared  out  before  the  operation, 
and  the  most  satisfactory  aperient  is  castor  oil;  about  half  an  ounce  should 
be  administered  over  night,  followed  by  a  plain  water  or  soap  and  water 
enema  in  the  morning.  The  latter  is  made  by  rubbing  up  Castile  soap 
in  warm  water  till  a  pretty  thick  lather  is  formed,  and  about  a  pint  is 
injected.  Where  the  patient  cannot  take  castor  oil,  or  where  it  causes 
much  griping,  compound  liquorice  powder  does  very  well,  and  a  teaspoonful 
at  night,  followed  by  an  enema  in  the  morning,  will  generally  suffice.  The 
chief  reason  for  clearing  out  the  bowels,  even  though  they  may  have  been 
acting  regularly  beforehand,  is  that  the  patient  is  generally  constipated 
after  an  operation  and  his  digestion  is  more  or  less  disordered ;  and,  further, 
it  is  important  to  get  rid  of  material  which,  by  decomposing,  may  cause 
trouble,  the  septic  products  being  absorbed  and  diminishing  the  patient's 
vitality.  The  evacuation  of  the  bowels  is  also  of  importance  in  certain 
operations — for  example,  in  piles — where  steps  are  taken  after  the  operation 
to  delay  their  action  for  some  time. 

The  most  favourable  time  for  an  operation  is  the  early  morning, 
and  that  for  two  reasons.  In  the  first  place  the  patient,  especially  if  he 
has  passed  a  good  night,  has  not  so  long  to  worry  and  excite  himself 
about  the  operation  as  when  a  later  hour  is  chosen;  and,  in  the  second 
place,  he  does  not  miss  his  food.  It  is  very  important,  particularly  in 
the  case  of  nervous  patients,  to  secure  a  good  night's  rest  before  the 
operation,  and  in  most  cases  there  is  no  objection  to  the  administration 
of  a  narcotic,  preferably  a  quarter  of  a  grain  of  morphine,  subcutaneously 
at  bedtime.  If  there  be  any  reason  against  the  use  of  morphine,  such  as 
renal  disease,  the  fear  of  headache,  sickness,  etc.,  the  administration  of 


HEMORRHAGE.  127 

20  grains  of  sulphonal  two  hours  before  bedtime  for  two  evenings  preceding 
the  operation  may  be  substituted. 

Selection  of  room  and  its  preparation. — in  private  practice  a  room 
with  a  good  light  should  be  chosen,  and  a  narrow  table  of  sufficient 
height  is  essential  to  comfort  For  this  purpose,  either  a  kitchen  table 
or  two  small  dressing  tables  placed  end  to  end  answer  the  purpose  per- 
fectly; if  these  be  unobtainable,  a  couple  of  trestles  with  a  board  resting 
upon  them  can  usually  be  fitted  up.  In  town  practice,  it  is  sometimes 
advisable  to  carry  one's  own  operating  table,  and  light  tables  for  this 
purpose  can  now  be  obtained  of  most  instrument  makers.  Upon  the  table 
are  placed  a  folded  blanket  and  a  pillow,  and  over  the  blanket,  opposite 
the  seat  of  operation,  is  laid  a  piece  of  mackintosh  covered  with  a  folded 
sheet,  so  as  to  keep  the  blanket  and  the  patient's  clothing  dry.  The 
mackintosh  should  not  be  spread  over  the  whole  table,  as  is  customary 
among  nurses,  for,  if  this  be  done,  the  fluid  soaks  into  the  patient's  clothes, 
and  he  is  very  soon  lying  in  a  pool  of  water.  The  mackintosh  should  be 
limited  to  the  seat  of  operation,  covered  with  a  thickly  folded  sheet,  and 
tucked  into  the  clothing  above  and  below  that  area. 


DANGERS   OF   OPERATION,   AND   HOW   GUARDED   AGAINST. 

The  chief  immediate  risks  of  the  operation  are  the  dangers  of  the 
anaesthetic,  loss  of  blood  and  shock ;  of  somewhat  less  importance  is  the 
occurrence  of  syncope,  while  the  risks  of  the  introduction  of  sepsis  must 
never  be  lost  sight  of.  The  first  and  last  of  these  points  are  dealt  with 
in  their  proper  place;  we  may  here,  however,  consider  the  others. 

Haemorrhage. 

The  question  of  bleeding  is  one  of  great  importance.  Bleeding  may 
be  arterial,  venous,  or  capillary  in  nature.  In  arterial  bleeding  blood  of  a 
bright  red  colour  spurts  from  the  cut  vessel  synchronously  with  the  systole 
of  the  heart,  and  flows  continuously  during  the  diastole.  In  venous 
bleeding  there  is  a  steady  flow  of  dark  blood,  except  in  the  case  of  the 
veins  of  the  neck,  where  it  flows  in  jets  at  each  expiration  with  a  steady 
flow  between.  Capillary  bleeding  is  an  oozing  from  the  surface  of 
the  wound. 

Mode  of  spontaneous  arrest  of  bleeding. — Bleeding  from  any  of 
these  sources  may  cease  spontaneously,  or  special  means  may  be  necessary 
to  arrest  it.  The  mode  in  which  haemorrhage  ceases  spontaneously 
differs  according  to  the  blood-vessels  concerned  in  the  bleeding.  In  the 
case  of  the  arteries,  when  divided  transversely  the  circular  fibres  of  the 
muscular  coat  contract  so  that  the  orifice  of  the  vessel  is  narrowed ;  at 
the  same  time  the  internal  and  middle  coats  curl  up  in  the  interior  of 
the  vessel,  and  the  longitudinal  fibres  contract  and  shorten  it,  so  that  it 


128  WOUNDS. 

retracts  within  its  sheath.  As  a  result,  there  is  clotting  of  the  blood;  as 
soon  as  the  blood  comes  in  contact  with  tissues  which  are  injured,  or 
which  are  not  similar  to  the  healthy  lining  membrane  of  the  vessels,  it 
undergoes  coagulation.  Consequently,  as  soon  as  the  blood  escapes  from 
the  vessel,  clotting  tends  to  take  place,  unless  the  escape  of  blood  be  so 
free  that  the  clot  is  swept  away  by  it.  In  the  case  of  small  vessels, 
clotting  occurs  where  the  blood  comes  in  contact  with  the  divided  coats, 
more  especially  between  the  vessel  and  the  sheath,  and  the  clot  formed 
there  tends  by  its  pressure  to  still  further  occlude  the  ends  of  the  artery. 
This  clot  forms  a  mechanical  obstacle  to  the  escape  of  the  blood  (provided 
that  the  force  of  the  blood  stream  be  not  sufficient  to  expel  it),  and  it 
very  soon  extends  upwards  into  the  interior  of  the  vessel,  in  most  cases  as 
far  as  the  nearest  collateral  branch.  The  result  is  that  a  conical  wedge 
of  blood  clot  is  formed  inside  the  vessel  which  is  very  effectual  in  bringing 
about  the  cessation  of  bleeding.  This,  then,  is  the  natural  mode  of  arrest 
of  haemorrhage  in  divided  arteries — the  contraction  and  retraction  of  the 
coats,  the  curling  up  of  the  internal  and  middle  coats,  the  clotting  of  the 
blood  between  the  artery  and  its  sheath,  compression  of  the  end  of  the 
vessel,  the  formation  of  a  plug  or  clot  in  the  open  orifice,  and  the  ex- 
tension upwards  of  a  conical  wedge  of  blood  clot  towards  the  nearest 
collateral  branch.  As  time  goes  on  cells  spread  into  this  blood  clot  (in 
the  first  instance  they  are  leucocytes,  but  later  on  plasma  cells,  cells 
derived  from  the  endothelium,  and  from  the  connective  tissues  in  the 
neighbourhood) ;  these  cells  organize  and  form  fibrous  tissue,  so  that  by 
and  bye  the  divided  end  of  the  vessel  becomes  completely  occluded  by 
fibrous  tissue  and  shrinks  up.  Ultimately  a  small  fibrous  cord  is  all  that 
remains  to  represent  the  vessel  from  the  seat  of  division  to  the  nearest 
collateral  branch.  When  an  artery  is  only  partially  cut  across,  the  con- 
traction and  retraction  of  its  coats  tend  to  enlarge  the  orifice,  and  so  to 
increase  bleeding  rather  than  diminish  it,  and  in  these  cases  the  natural 
haemostatic  process  cannot  occur  until  the  vessel  is  completely  divided. 

Capillary  bleeding  ceases  simply  as  the  result  of  coagulation  of  blood 
in  the  capillaries.  Venous  bleeding,  where  the  vein  is  only  partially  divided, 
ceases  as  the  result  of  the  formation  of  a  small  clot  outside  the  vein, 
and  the  subsequent  sealing  of  the  part  with  lymph  ;  where  the  division 
is  complete,  clothing  occurs  and  the  vein  becomes  closed  by  adhesion. 
It  does  not  at  all  necessarily  follow  that  a  clot  will  form  in  the  interior 
of  a  vein  if  it  be  only  partially  divided. 

Means   of  controlling   Haemorrhage. 

Where  the  artery  is  large  the  bleeding  will  not  stop  spontaneously, 
and  some  artificial  means  must  be  adopted  to  arrest  it.  Capillary 
bleeding  is,  on  the  other  hand,  only  troublesome  in  cases  of  haemophilia, 
where  coagulation  of  the  blood  does  not  take  place  properly,  and  very 


MEANS   OF   CONTROLLING   HAEMORRHAGE.  129 

persistent  oozing  may  occur.  Venous  bleeding  usually  ceases  spontaneously, 
if  a  vein  be  not  completely  divided,  except  where  severe  coughing  or 
crying  gives  rise  to  an  obstruction  to  the  flow  of  blood  through  the 
veins,  and  leads  to  jetting  out  of  blood  through  the  divided  wall. 

Tourniquet.— In  dealing  with  haemorrhage,  it  is  necessary  to  consider 
not  only  its  arrest,  but  also  its  prevention.  Under  certain  circumstances 
it  is  advisable  to  arrest  the  circulation  in  the  part  upon  which  an  operation 
is  being  performed.  Formerly  this  was  done  by  means  of  a  tourniquet, 
a  band  tied  tightly  round  the  limb,  furnished  with  a  screw  and  a  pad, 
which  was  placed  over  the  artery,  and  screwed  up  till  the  circulation 
through  the  vessel  was  arrested. 

Esmarch's  bandage.— While  the  tourniquet  arrested  the  circulation 
through  the  main  vessel,  it  did  not  stop  the  collateral  bleeding.  At  the 
present  time  an  elastic  band,  with  which  the  name  of  Esmarch  is  associated, 
is  tied  firmly  round  the  limb  at  the  upper  part,  and  in  this  way  the  whole 
circulation,  not  merely  in  the  main  vessel,  but  in  all  the  other  vessels  of 
the  limb,  is  effectually  controlled.  In  the  case  of  weakly  patients — for 
example,  in  cases  of  amputation — it  is  also  of  importance  to  preserve  the 
blood  which  is  already  present  in  the  limb ;  or  to  empty  the  limb  of 
blood,  for  example,  in  suturing  nerves  where  it  is  necessary  to  render  the 
field  of  operation  entirely  bloodless.  Esmarch's  plan  is  to  bandage  the  limb 
spirally  from  the  extremity  upwards,  by  means  of  a  broad  elastic  bandage 
very  firmly  applied,  so  as  to  expel  all  the  blood  from  the  vessels  ;  when 
the  upper  part  of  the  limb  is  reached,  an  elastic  tube  or  cord  is  applied 
transversely  around  it,  and  then  the  spiral  elastic  bandage  is  taken  off. 
The  objection  to  this  method  is,  in  the  first  place,  that  it  is  frequently 
undesirable,  and,  in  the  second  place,  it  is  unnecessary.  It  is  a  very  un- 
desirable method  in  cases  of  tumours  or  of  suppuration,  as  in  them  the 
elastic  bandage  is  very  apt  to  squeeze  pus  or  tumour  substance  into  the 
tissues  or  the  vessels  during  its  application,  and  thus  serious  results  may 
be  caused. 

Lister's  method.— On  the  other  hand,  the  plan  introduced  by  Lord 
Lister,  of  elevating  the  limb  for  a  few  minutes  before  applying  the  elastic 
tourniquet,  suffices  to  empty  the  limb  of  blood.  If  the  limb  be  elevated 
the  veins  immediately  collapse,  and  reflexly  the  main  arteries  contract,  so 
that  the  limb  becomes  practically  bloodless  if  the  position  be  maintained 
for  two  or  three  minutes.  When  this  has  been  done,  and  while  the  limb 
is  still  raised,  an  elastic  bandage  is  applied  in  a  circular  manner  around 
its  upper  part.  In  this  way,  a  field  practically  as  free  from  blood  as  by 
Esmarch's  method  is  obtained  without  any  risk  of  disseminating  pus  or 
tumour  substance. 

It  is  only  in  a  few  cases  that  this  bloodless  plan  is  of  real  advantage. 
It  is  of  great  value  in  operations  such  as  suture  of  nerves  or  tendons, 
where  the  delicate  dissections  so  often  called  for  would  be  marred  by 
the  presence  of  blood  in  the  wound.  In  amputations  the  arrest  of  the 

i 


130 


WOUNDS. 


haemorrhage  is  very  important,  and  the  main  vessel  and  its  larger  branches 
can  be  tied  before  the  blood  is  allowed  to  flow  through  the  vessels  again. 
It  is  also  useful  in  operations  for  necrosis,  as  it  allows  the  surgeon  to 
distinguish  easily  between  the  living  and  the  dead  part;  but  it  is  not  so 
good  in  cases  of  tubercular  joints,  where  the  accurate  recognition  of  the 
diseased  tissues  depends  to  a  considerable  extent  on  the  vascularity  of  the 
part. 

Objections  to  "bloodless  methods." — There  is  one  great  general  objection 
to  the  use  of  Esmarch's  bandage,  and  the  principle  of  bloodless  operations 
generally.  It  is  that,  if  the  operation  be  a  prolonged  one,  the  after-bleeding 
is  very  severe,  and  the  amount  of  blood  lost  by  the  patient  is  probably 
as  great  when  the  bandage  is  used  as  when  it  is  not.  Further  than  this, 
more  time  is  spent  over  the  operation,  because  an  unduly  large  number 
of  vessels  have  to  be  tied,  and  the  wound  cannot  be  sewn  up  until  the 
oozing  has  stopped.  When  the  bandage  is  removed  after  it  has  been  on 
for  some  considerable  time  the  vessels  dilate,  the  limb  is  seen  to  flush 
and  become  much  redder  than  its  fellow,  and  there  is  in  fact  a  certain 
amount  of  vaso-motor  paralysis.  As  a  consequence  of  this  many  of  the 
vessels  go  on  bleeding,  and  require  ligature ;  had  the  bandage  not  been  used 
the  bleeding  from  these  vessels  would  have  stopped  almost  immediately. 

Ligature.— Of  the  methods  employed  for  the  artificial  arrest  of 
haemorrhage  the  best  and  most  generally  used  is  that  of  ligature.  Where 
an  artery  is  of  such  a  size  that  the  bleeding  does  not  cease  spontaneously 
soon  after  its  division,  it  is  well  to  apply  a  ligature  to  it.  The  effect 
of  a  ligature  applied  to  an  artery  is  to  divide  the  internal  and  middle 
coats,  which  curl  up  in  the  interior  of  the  vessel,  and,  further,  to  constrict 
the  external  coat  firmly,  so  as  to  prevent  the  escape  of  blood  from  the 
vessel.  Two  varieties  of  material  are  used  for  ligatures,  either  absorbable 
materials,  or  those  which  are  not  absorbable  or  are  absorbed  only  with 
very  great  difficulty ;  the  best  of  the  former  materials  is  catgut.  Catgut, 
unless  specially  prepared  so  as  to  harden  it,  is  very  quickly  absorbed,  and 
unprepared  catgut  in  the  tissues  will  not  hold  for  more  than  a  few  hours. 
Lord  Lister  has  devoted  much  time  to  the  subject  of  the  preparation  of 
this  material,  and  when  prepared  as  he  recommends,  it  will  hold  for  some 
weeks  before  it  begins  to  disappear.  A  reliable  form  is  Lister's  chromicized 
catgut,  prepared  as  described  in  the  Lancet  for  February  5th,  1881.  The 
one  that  finds  most  favour  at  the  present  time  is  that  prepared  by  means 
of  sulphurous  acid,  and  is  known  as  Lister's  sulpho-chromic  catgut.  Cat- 
gut in  its  raw  state  is  full  of  bacteria,  because  putrefaction  plays  a  part 
in  its  manufacture,  the  gut  being  allowed  to  decompose  to  a  certain 
extent,  in  order  to  permit  the  mucous  membrane  to  be  easily  stripped  off 
the  muscular  coat.  Hence,  as  it  comes  from  the  manufacturer,  it  contains 
living  bacteria  and  their  spores.  In  the  process  of  preparation  recom- 
mended by  Lord  Lister  a  considerable  amount  of  disinfection  takes  place, 
so  that  the  chromicized  catgut  immediately  after  it  is  prepared  is  prac- 


MEANS   OF   CONTROLLING    HAEMORRHAGE.  131 

tically  aseptic.  When  kept  in  the  dry  state,  however,  it  soon  becomes 
covered  with  dust,  and,  unless  properly  disinfected  before  use,  may  give 
rise  to  sepsis.  It  should,  therefore,  never  be  used  dry,  or  straight  from 
the  surgical  instrument  makers,  but  should  be  allowed  to  soak  for  about 
a  week  in  a  1-20  watery  solution  of  carbolic  acid,  and  it  will  then  be 
found  quite  satisfactory,  and  suppuration  in  connection  with  the  ligatures 
will  not  occur.  The  catgut  usually  sold  in  bottles  filled  with  carbolized 
oil  should  be  avoided :  it  is  unreliable  for  several  reasons.  Of  course, 
catgut  should  never  be  disinfected  by  boiling,  as  the  material  swells  up 
and  becomes  useless  for  purposes  of  ligature.  The  chromicized  catgut 
should  be  used  fine,  except  in  the  case  of  a  large  vessel  such  as  the 
femoral  or  axillary  artery,  and  the  ends  of  the  ligature  should  be  cut 
quite  short. 

Among  the  non-absorbable  materials  fine  silk  is  a  good  deal  used  for 
ligatures,  and  there  is  no  real  objection  to  it  if  it  be  quite  aseptic.  It  is 
usually  rendered  aseptic  by  boiling,  and  is  then  afterwards  kept  in  a  1-20 
solution  of  carbolic  acid.  Before  using,  it  is  well  to  wash  out  the  carbolic 
solution  with  one  of  sublimate  (1-2000).  These  ligatures,  like  the  catgut 
ones,  should  have  their  ends  cut  short.  There  is,  however,  no  special 
advantage  in  silk,  and  it  is  a  disadvantage  to  fill  the  wound  with  a  large 
number  of  ligatures  of  a  material  which  is  not  readily  absorbed. 

When  an  aseptic  ligature  is  tied  round  a  vessel,  in  the  course  of  a  few 
hours  it  becomes  buried  in  lymph,  and  this  lymph  subsequently  becomes 
penetrated  with  cells  which  organize  into  fibrous  tissue,  and  which  at  the 
same  time  eat  away  the  outer  surface  of  the  ligature,  so  that  by  and  by 
these  cells  penetrate  in  between  its  strands.  In  this  way  the  ligature  is 
ultimately  replaced  by  young  fibrous  tissue.  In  the  case  of  silk  a  very 
much  longer  time  is  occupied  by  this  process  than  in  the  case  of  catgut, 
and  it  may  be  months,  or  even  a  year  or  two,  before  the  silk  has  dis- 
appeared, and  sometimes  small  abscesses  form  and  the  silk  is  discharged. 

Cautery.— In  the  case  of  vessels  situated  in  parts  where  ligatures  can- 
not be  applied,  the  bleeding  may  sometimes  be  arrested  by  means  of  the 
cautery,  the  most  convenient  form  being  that  known  as  Paquelin's  cautery. 
It  must  not  be  used  white  hot,  as  in  that  case  it  will  cut  through  the  vessel, 
and  bleeding  will  simply  persist ;  it  should  be  allowed  to  cool  until  it  is 
hardly  red,  and  if  a  hot  point  like  this  be  held  in  contact  with  the  vessel, 
it  sears  the  tissues  so  that  they  stick  together,  and  clotting  occurs  inside 
the  artery. 

Torsion. — Another  way  in  which  arterial  bleeding  may  be  arrested  is 
by  torsion.  The  object  of  torsion  is  to  twist  the  end  of  the  artery  so  that 
the  middle  and  internal  coats  are  ruptured  and  curl  up,  while  the  twisted 
external  coat  forms  an  obstacle  to  the  escape  of  blood.  In  order  to  do 
this,  the  artery  must  be  fixed  above  the  point  where  rupture  of  the  coats 
is  required,  as  otherwise,  in  the  case  of  a  large  artery  at  any  rate,  the  only 
effect  would  be  to  twist  the  artery  round  and  round  in  its  sheath  for  a 


132 


WOUNDS. 


great  distance  without  attaining  the  required  result.  In  the  case  of  a 
large  artery,  therefore,  the  vessel  is  pulled  out  of  its  sheath  and  grasped 
transversely  to  its  long  axis  with  a  pair  of  forceps  above  the  point  where 
the  torsion  is  to  be  employed,  and  the  cut  end  of  the  artery  is  then 
grasped  by  another  pair  of  forceps,  and  twisted  till  the  coats  are  felt  to 
give  way  and  till  a  sufficient  twisted  piece  is  left.  Four  complete  revolu- 
tions generally  suffice.  In  the  case  of  small  vessels,  it  usually  suffices  to 
get  the  artery  as  free  from  the  surrounding  tissues  as  possible,  to  grasp 
the  tissues  above  the  artery  with  the  fingers  of  one  hand,  compress 
them  firmly,  and  then  twist  up  the  part  seized  by  the  forceps  with  the 
other  hand.  Although  torsion  answers  very  well  in  many  cases,  we  cannot 
recommend  it  as  a  substitute  for  ligature.  It  was  introduced  before  the 
aseptic  period,  when  ligatures  had  to  separate,  and  when,  therefore,  there 
was  a  danger  of  secondary  haemorrhage ;  but  nowadays,  when  ligatures  are 
cut  short  and  never  separate  from  the  divided  ends  of  the  artery,  there 
is  no  risk  of  secondary  hemorrhage,  and  torsion,  except  for  small  vessels, 
has  become  more  or  less  obsolete. 

Pressure. — Pressure  is  also  a  very  important  method  of  arresting 
haemorrhage,  more  especially  of  the  venous  or  capillary  variety ;  indeed, 
venous  bleeding  can  be  most  readily  arrested  by  it,  and  in  many  cases 
where  it  is  undesirable  to  have  ligatures  on  the  surface  of  the  wound,  as 
for  instance  in  cases  of  operations  about  the  lips,  the  surgeon  makes 
use  partly  of  cold  and  partly  of  pressure  to  complete  the  arrest  of  the 
haemorrhage.  The  pressure  stops  the  flow  of  blood  through  the  vessel 
while  a  clot  is  being  formed.  In  speaking  of  pressure,  we  must  mention 
the  "graduated  compress."  Where  the  bleeding  point  is  deeply  seated, 
and  where  it  is  not  desired  to  open  up  the  wound,  pressure  may  be 
employed  to  arrest  the  haemorrhage.  If,  however,  the  pressure  be  simply 
applied  in  the  form  of  a  pad  over  the  surface  of  the  wound,  the  bleeding 
may  go  on  in  the  interior;  a  good  example  is  bleeding  from  the  cavity  of 
a  tooth  after  the  latter  has  been  extracted.  Cases  of  this  kind  require  the 
application  of  a  graduated  compress,  that  is  to  say,  a  tiny  piece  of  gauze 
or  lint  is  placed  actually  on  the  bleeding  point,  then  pieces  gradually  in- 
creasing in  size  are  added  until  a  conical  pad  is  formed,  the  outer  part 
of  which  projects  well  above  the  surface.  Then  by  means  of  a  bandage, 
or  in  the  case  of  a  tooth  by  fixing  the  two  jaws  together,  pressure  is 
applied  through  the  •  cone  actually  on  to  the  bleeding  point. 

Temporary  pressure  by  forceps. — A  good  deal  can  also  be  done  in  the 
way  of  arresting  haemorrhage  from  small  vessels  by  pinching  them  tightly. 
The  vessels  are  seized  as  free  as  possible  from  surrounding  tissue  with  the 
point  of  a  strong  forceps,  such  as  Spencer  Wells',  or,  perhaps  even  better, 
those  devised  by  Greig  Smith  (see  Fig.  42),  and  are  held  in  them  for  some 
little  time.  If,  as  the  operation  proceeds,  the  various  bleeding  points  be 
compressed  in  this  way  and  the  forceps  left  on,  it  will  be  found  that 
by  the  time  the  operation  is  completed  and  the  forceps  removed,  only 


MEANS   OF   CONTROLLING    HEMORRHAGE. 


133 


a  very  small  number  of  the  vessels  bleed  and  require  ligature.  Thus, 
by  the  use  of  these  forceps,  a  great  deal  of  time  is  saved  in  the  course 
of  a  long  operation.  In  the  case  of  a  breast  amputation,  probably  not 
more  than  six  or  eight  vessels  will  require  ligature,  whereas  if  all  the 
bleeding  points  were  ligatured,  as  was  formerly  done,  the  number  of 


A 


B 


FIG.  42. — PRESSURE  FORCEPS  FOR  ARREST  OF  HAEMORRHAGE.  The  above  are  the 
varieties  in  common  use.  A,  Spencer  Wells'  ;  upon  which  most  forceps  for  this  purpose 
are  modelled.  B,  Lawson  Tail's  ;  very  similar  to  Spencer  Wells',  but  so  tapered  at  the 
points  as  to  facilitate  the  application  of  a  ligature.  C,  Greig  SimtKs  ;  these  forceps  are 
designed  to  crush  the  walls  of  a  vessel  firmly  together,  and  at  the  same  time  to  cut 
through  their  inner  and  middle  coats.  The  full-size  illustration  of  the  blade  shows  how 
this  is  done. 

ligatures  might  amount  to  thirty  or  forty,  or  even  more.  The  action  of 
the  forceps  is  to  compress  the  end  of  the  artery,  and  if  they  are  kept  on 
for  a  little  time,  when  they  are  removed  lymph  is  already  effused,  and 
sticks  the  compressed  ends  together,  and  a  blood  clot  has  formed  in  the 
interior. 

Horsley's  wax. — In  the  case  of  bleeding  from  bone,  etc.,  Horsley  has 
introduced  an  aseptic  wax  which  can  be  applied  over  the  bleeding  point, 
so  as  to  close  the  hole  in  the  bone  from  which  the  blood  comes.  The  com- 
position of  this  wax  is  beeswax  7  parts,  almond  oil  i  part,  and  salicylic 
acid  i  part.  When  not  in  use,  the  wax  is  kept  in  a  vessel  of  1-20  car- 
bolic solution.  When  it  is  required  for  use,  a  small  piece  is  pinched  off, 
softened  by  rolling  between  the  fingers,  which,  of  course,  should  be 
aseptic,  and  then  pressed  well  into  the  part  of  the  bone  from  which  the 
blood  is  coming.  The  wax  does  not  give  rise  to  any  trouble  in  the  healing 
of  the  wound. 

Cold. — There  are  various  other  ways  in  which  bleeding  may  be  arrested, 
and  which  are  specially  applicable  to  oozing  from  small  vessels  or  capil- 
laries which  cannot  be  controlled  by  the  means  already  mentioned.  The 


134  WOUNDS. 

chief  of  these  methods  are  those  that  tend  to  cause  the  contraction  of  the 
coats  of  the  vessel,  namely,  the  use  of  cold  or  heat.  The  application  of 
cold  to  the  skin  over  a  bleeding  part  will  lead,  in  the  first  place,  to 
contraction  of  the  cutaneous  vessels,  and  reflexly  to  contraction  of  those 
of  the  deeper  parts.  For  example,  in  operations  about  the  mouth  or  lips, 
such  as  those  for  cleft  palate  or  hare-lip,  bleeding  can  be  very  quickly 
arrested  by  slapping  the  face  with  a  cold  wet  towel,  or  dashing  cold 
water  upon  it,  or,  if  that  fail,  by  the  application  of  ice  to  the  neighbourhood 
of  the  bleeding  part. 

The  use  of  Leiter's  tubes,  which  have  already  been  mentioned  in  dealing 
with  inflammation  (see  p.  9),  is  a  very  effectual  method  of  checking  bleed- 
ing. For  example,  in  cases  of  haemorrhage  from  the  urethral  mucous 
membrane  occurring  sometimes  as  the  result  of  gonorrhoea,  where  no  direct 
method  of  haemostasis  can  be  employed,  a  very  excellent  method  is  to  coil 
Leiter's  tubes  around  the  penis,  and  pass  a  stream  of  ice-cold  water 
through  them.  As  the  penis  contracts  with  the  cold,  it  is  also  well  to  pass 
a  straight  catheter  a  short  distance  up  the  urethra  before  fixing  on  the  coil. 
The  result  of  application  of  cold  in  this  manner  is  that  contraction  of  the 
vessels  of  the  skin  with  subsequent  contraction  of  the  deeper  vessels  occurs, 
and  if  this  be  kept  up  for  a  short  time  coagulation  will  follow,  and 
permanent  occlusion  of  the  bleeding  vessels  result.  A  piece  of  lint  should 
be  placed  on  the  skin  beneath  the  coil,  and  on  account  of  the  great  cold 
which  the  use  of  these  tubes  may  produce,  the  part  should  be  looked  at 
from  time  to  time  to  see  if  it  is  becoming  blue  as  the  result  of  inter- 
ference with  the  circulation  through  it,  in  which  case  the  use  of  the  coil 
must,  temporarily  at  least,  be  suspended. 

Heat. — Almost  equally  efficacious  in  arresting  bleeding  is  heat,  and 
douching  the  bleeding  part  with  hot  water  has  a  powerful  haemostatic 
effect.  The  temperature  of  the  water  generally  used  is  from  108°  to  115° 
Fahr.,  and  the  affection  in  which  it  is  chiefly  employed  is  postpartum 
haemorrhage,  the  uterus  being  freely  flooded  with  water  at  this  temperature. 

Styptics. — Haemorrhage  may  also  be  arrested  by  producing  coagu- 
lation of  the  blood  as  it  escapes  from  the  vessel,  and  this  is  done  by  the 
use  of  styptics.  In  employing  styptics  it  is  useless  to  pour  the  solution 
into  or  to  swab  a  bleeding  wound  with  it.  The  bleeding  must,  in  the  first 
instance,  be  temporarily  arrested,  because,  if  the  styptic  is  to  act  efficiently, 
the  clot  produced  by  it  must  form  not  on  the  surface  of  the  wound,  but 
actually  in  the  orifice  of  the  bleeding  vessel.  Hence  the  bleeding  area 
is  pinched  up  between  the  finger  and  thumb,  and  the  bleeding  thus  tem- 
porarily arrested;  it  is  then  painted  over  with  the  styptic  solution,  and  the 
pressure  is  maintained  for  a  short  time  in  order  to  keep  the  wound  from 
bleeding,  and  to  give  the  styptic  time  to  act.  The  styptics  usually  employed 
are  the  liquor  ferri  perchlor,  B.P.,  or  the  liquor  ferri  perchloridi  fort, 
mixed  with  equal  parts  of  glycerine,  or  tincture  of  matico.  While  per- 
chloride  of  iron  is  the  best  styptic,  it  is  objectionable  in  that  it  very  often 


MEANS   OF   CONTROLLING   HEMORRHAGE. 


135 


causes  a  slough  on  the  surface  of  the  wound.  In  cases  of  operations 
upon  the  mouth  or  upon  some  part  where  sepsis  subsequently  occurs,  this 
slough  is  a  source  of  danger,  as  septic  micro-organisms  are  likely  to  grow 
in  it. 

Fibrin-ferment.— In  connection  with  styptics  may  be  mentioned  the 
fibrin-ferment  introduced  by  Prof.  A.  E.  Wright,  of  Netley,  for  the  pur- 
pose of  checking  excessive  oozing  from  large  raw  surfaces.  A  piece  of 
sterilized  lint,  sponge,  or  muslin  is  saturated  with  the  ferment  solution  and 
laid  upon  the  oozing  surface,  so  as  to  come  thoroughly  into  contact  with 
all  the  bleeding  points.  Its  action  is  to  induce  rapid  coagulation  of  the 
blood  as  it  issues  from  the  vessels,  and,  provided  that  these  be  small,  the 
result  is  very  good.  In  our  hands  it  has  seemed  of  value  in  cases  such 
as  excision  of  superior  maxilla,  operations  about  the  throat,  etc. ;  it  must, 
however,  be  freshly  prepared,  and  is  difficult  to  obtain. 

Drugs. — Lastly,  we  have  the  internal  use  of  drugs  which  cause 
contraction  of  the  vessels,  of  which  the  most  notable  is  ergot.  The  fluid 
extract  of  ergot,  given  in  doses  of  from  30  to  60  minims  every  hour,  or 
even  more  frequently,  for  three  or  four  doses,  is  a  very  valuable  agent. 
Where  a  still  more  rapid  effect  is  desired,  a  dose  of  one-fiftieth  of  a  grain 
of  ergotinine  injected  subcutaneously  may  be  employed,  and  this  may  be  re- 
peated two  or  three  times.  A  solution  of  ergotine  may  also  be  employed 
in  doses  of  one  to  two  grains  injected  at  right  angles  to  the  surface  of 
the  skin  well  into  the  muscular  tissues.  Among  other  substances  used  for 
the  same  purpose  may  be  mentioned  gallic  acid,  which  is  given  in  doses 
of  ten  grains  every  two  or  three  hours. 

Another  drug  that  has  been  employed  for  the  purpose  of  increasing  the 
coagulability  of  the  blood  is  chloride  of  calcium,  which  may  be  given  half  an 
hour  before  operation  in  doses  of  30  grains  by  the  mouth,  or  better,  since 
it  is  likely  to  induce  vomiting,  in  doses  of  i  drachm  to  the  pint  of  water 
by  the  rectum.  If  it  be  employed,  the  cases  for  its  use  must  be  carefully 
selected.  Its  power  of  increasing  the  coagulability  of  the  blood  is 
undoubtedly  very  great,  and  therefore  where  there  is  much  shock,  and  the 
circulation  is  much  enfeebled,  it  may  cause  serious  harm  by  bringing  about 
thrombosis  in  the  large  veins,  and  its  use  is  therefore  not  to  be  recom- 
mended where  great  shock  is  feared. 

Symptoms  of  serious  loss  of  blood. — The  next  point  for  considera- 
tion is  the  treatment  of  cases  where  so  much  blood  has  been  lost,  either 
from  continuous  oozing  from  the  vessels,  or  from  the  sudden  escape  from 
some  larger  trunk,  that  the  patient's  life  is  endangered.  Bleeding  may 
also  occur  under  the  dressing,  or  into  the.  abdomen  in  cases  of  abdominal 
operations,  after  the  patient  has  been  removed  to  bed,  and  it  is  necessary 
that  the  surgeon  should  be  able  to  recognize  the  symptoms  of  loss  of  blood. 
These  are  pallor,  a  rapid,  soft,  and  feeble  pulse,  gasping  or  sighing  respira- 
tion from  imperfect  oxygenation  of  the  blood,  and  a  tendency  to  twitching 
of  the  muscles ;  the  patient  soon  loses  consciousness.  The  most  typical 


136  WOUNDS. 

sign  is  the  restlessness  of  the  patient :  he  gasps  for  air,  throws  himself 
about,  and  uncovers  his  chest  in  his  desire  to  get  more  air  into  his  lungs. 

Transfusion. — The  occurrence  of  these  symptoms  should  at  once  lead 
the  surgeon  to  assume  that  bleeding  is  going  on,  and  the  dressing  should 
therefore  be  removed  immediately,  and,  if  necessary,  the  wound  opened  up 
with  the  view  of  securing  the  bleeding  point.  In  some  cases  the  patient's 
condition  may  be  so  bad  that  it  is  not  advisable  to  search  for  the  bleeding 
point,  lest  he  die  during  the  attempt  to  find  it,  and  here  pressure  must  be 
resorted  to  for  a  time.  In  any  case,  if  the  loss  of  blood  be  serious,  measures 
must  be  taken  to  restore  the  volume  of  fluid  in  the  blood-vessels  by  means 
of  transfusion.  The  fluid  used  for  transfusion  may  either  be  blood,  pure 
or  mixed  with  phosphate  of  soda  or  defibrinated,  or  an  indifferent  fluid, 
such  as  the  ordinary  normal  saline  solution.  As  regards  the  use  of  blood, 
either  pure  or  mixed  with  phosphate  of  soda,  it  has  been  found  that  the 
red  blood  corpuscles  introduced  soon  die,  and  have  comparatively  little  effect 
as  carriers  of  oxygen,  and  there  is  great  difficulty  and  risk  in  introducing 
pure  blood,  chiefly  owing  to  the  formation  of  coagula  in  the  instruments, 
or  the  detachment  of  coagula  from  them  giving  rise  to  pulmonary  embolism. 
Even  defibrinated  blood  is  not  free  from  this  last  objection.  On  the  other 
hand,  indifferent  fluids  answer  the  purpose  of  giving  the  heart  enough 
fluid  to  contract  upon,  and  so  enabling  it  to  drive  what  blood  corpuscles 
remain  through  the  circulation,  thus  keeping  the  patient  alive  till  fresh 
blood  has  been  manufactured. 

Hence,  nowadays,  the  most  common  material  for  transfusion  is  the 
ordinary  salt  solution  used  in  physiological  work,  that  is  to  say,  a  75  per 
cent,  solution  of  common  salt.  In  practice,  this  is  roughly  about  a  tea- 
spoonful  of  common  salt  to  the  pint  of  water.  The  water  should  be  boiled 
and  allowed  to  cool  by  standing  under  cover  or  in  ice  till  it  has  reached 
100°  Fahr.  In  cases  of  emergency,  however,  it  is  not  always  easy  to  get 
boiled  water,  and  if  the  water  has  to  be  boiled  and  cooled  too  much  time 
is  wasted,  and  therefore  it  is  necessary  to  risk  the  introduction  of  organisms 
by  mixing  the  water  from  the  kitchen  boiler  with  a  sufficient  amount  of 
ice  or  cold  water  to  reduce  the  temperature  to  the  required  degree.  In 
introducing  the  saline  solution,  a  vein  is  exposed  (most  conveniently  the 
median  basilic),  a  double  ligature  of  catgut  is  passed  around  it,  divided  in 
the  centre,  and  the  two  threads  separated  from  one  another.  An  oblique 
cut  is  then  made  through  about  half  the  calibre  of  the  vessel  between  the 
two  threads,  and  the  nozzle  of  a  suitable  cannula  is  inserted  into  the 
opening  and  tied  in  by  the  upper  of  the  two  threads  of  the  double 
ligature,  the  vein  also  being  ligatured  below  by  the  lower  thread,  so  that 
the  blood  does  not  escape  from  the  distal  end.  There  may  be  some 
difficulty  in  making  the  vein  prominent  in  cases  where  the  circulation  is 
very  feeble.  If  it  cannot  be  seen  by  lightly  constricting  the  upper  arm, 
the  best  plan  is  to  make  a  transverse  cut  across  the  direction  of  the 
vessel  down  to  the  deep  fascia;  the  divided  ends  of  the  vein  can  then 


TRANSFUSION. 


137 


easily  be  seen,  the  distal  end  ligatured,  the  proximal  grasped  with  forceps, 
and  the  cannula  introduced  and  tied  in.  Before  the  cannula  is  tied  in 
a  piece  of  india-rubber  tubing  is  attached  to  it,  and  to  this  is  fitted  a 
glass  funnel,  or  the  barrel  of  a  glass  syringe  from  which  the  piston  has 
been  removed,  washed  in  carbolic  acid,  and  then  filled  completely  with 
salt  solution  and  the  tube  clamped  so  as  to  expel  all  the  air.  Care  must 
be  taken  that  no  air  gets  in  at  any  time.  The  funnel  is  held  from  two 
to  three  feet  above  the  level  of  the  patient,  the  clamp  is  opened,  and 
the  fluid  is  allowed  to  flow  gradually  into  the  vein  (see  Fig.  43),  care 


FIG.  43. — TRANSFUSION.  This  shows  the  method  of  using  the  barrel  of  an  ordinary- 
glass  syringe  as  a  funnel.  It  is  convenient  in  practice  to  have  a  clamp  upon  the  india- 
rubber  tube.  There  is  a  ligature  shown  in  the  illustration  upon  the  distal  side  of  the 
incision  in  the  vein,  the  one  on  the  proximal  side  serving  to  tie  in  the  cannula. 

being  taken  that  the  fluid  in  the  funnel  is  replenished  before  it  has  quite 
run  away,  as  otherwise  air  may  get  in  when  a  fresh  supply  of  the  fluid 
is  poured  in.  The  rapidity  of  the  flow  can  be  easily  controlled  by 
raising  the  funnel  more  or  less  above  the  level  of  the  heart;  this  can 
be  better  regulated  by  means  of  a  funnel  than  if  the  saline  solution  be 
injected  by  means  of  a  syringe.  The  amount  introduced  should  be  from 
one  to  three  pints.  The  condition  of  the  patient  has  to  be  carefully 
watched  during  its  introduction.  If  it  enter  too  rapidly,  the  fluid  that 
is  driven  from  the  heart  into  the  lungs  may  consist  of  pure  salt  solu- 
tion, and  consequently  signs  of  imperfect  aeration  of  the  blood  at  once 
become  evident ;  the  respiration  becomes  embarrassed,  and  twitchings 


138  WOUNDS. 

and  restless  movements  occur,  and  the  patient  may  die  at  once.  If 
any  symptoms  of  this  kind  occur,  the  tube  should  at  once  be  clamped 
so  as  to  arrest  the  flow  of  the  saline  solution  till  the  dangerous  symptoms 
have  passed  off.  Plenty  of  time  should  be  taken  in  introducing  the  fluid, 
certainly  from  20  minutes  to  half  an  hour,  and  it  is  well  to  stop  every 
now  and  then  to  allow  the  blood  in  the  body  to  be  mixed  thoroughly 
with  the  saline  solution.  In  many  cases,  where  the  condition  is  less  urgent, 
it  is  better  to  allow  the  fluid  to  be  absorbed  rather  than  to  inject  it  directly 
into  the  circulation,  and  this  may  be  done  either  by  injecting  the  salt 
solution  into  the  rectum,  two  or  three  pints  at  a  time,  or,  if  this  be  not 
retained,  it  may  be  injected  into  the  peritoneal  cavity,  or  even  into  the 
cellular  tissue,  especially  that  beneath  the  axillary  fascia.  In  this  way  the 
absorption  will  be  so  regulated  by  the  body  that  too  rapid  dilution  of  the 
blood  will  not  take  place.  It  may  be  necessary,  in  cases  where  a  very 
large  quantity  of  blood  has  been  lost,  to  repeat  the  operation  after  the 
lapse  of  an  hour  or  so.  Usually,  however,  unless  there  be  also  great  shock, 
one  transfusion  is  sufficient  to  tide  the  patient  over  till  a  sufficient  quantity 
of  fresh  corpuscles  has  been  manufactured. 

Transfusion  of  blood,  either  pure,  diluted  or  defibrinated,  has  so  little 
to  recommend  it  that  we  need  not  take  up  space  by  describing  the 
method. 

Shock. 

Shock  may  be  defined  as  a  state  of  great  depression  of  the  vital  activity, 
into  which  a  patient  passes  as  the  result  of  sudden,  severe,  or  prolonged 
irritation  of  the  peripheral  nerves,  especially  of  the  sympathetics.  The 
condition  seems  to  be  due  to  extreme  exhaustion  of  the  medulla  and 
spinal  cord,  resulting  in  marked  reduction  in  the  activity  of  all  the  vital 
functions.  Over-stimulation  of  sensory  nerves  leads  to  exhaustion  and 
temporary  suspension  of  function  of  the  corresponding  centres,  and  the 
longer  the  stimulation  is  continued  and  the  greater  its  activity,  the  more 
profound  and  prolonged  is  the  suspension  of  function,  and  the  less 
is  the  probability  of  recovery.  Much  depends  on  the  part  of  the  body 
operated  upon;  for  example,  a  great  deal  of  time  may  be  spent  in 
repairing  a  badly  united  or  un-united  fracture  of  the  extremities  without 
producing  anything  like  the  amount  of  shock  that  a  much  shorter  and 
gentler  operation  on  the  abdominal  cavity  will  cause,  especially  if  the 
peritoneum  be  inflamed.  Loss  of  blood  also  increases  the  risk  of  shock, 
and  it  is  thus  more  marked  in  operations  where  there  is  a  great  deal  of 
haemorrhage. 

Symptoms. — If  shock  comes  on  during  an  operation,  its  presence  is 
indicated  by  increasing  pallor  of  the  countenance  and  weakness  of  the 
pulse,  which  becomes  rapid,  dicrotic,  and  sometimes  irregular.  The  pupils 
become  dilated,  the  reflexes  are  slow,  there  is  often  sweating  about  the 
forehead,  and  the  skin  becomes  cold.  After  the  operation  the  pulse 


SHOCK.  139 

remains  bad  and  the  patient  cold,  and,  though  he  may  to  some  extent 
recover  consciousness,  his  senses  are  dull.  When  severe  shock  is  estab- 
lished the  probability  of  overcoming  it  is  not  great,  and  therefore  it  is 
highly  important  to  take  measures  beforehand  to  avoid  or  diminish  it  as 
far  as  possible. 

Treatment. — (a)  Prophylaxis. — We  have  already  referred  to  some  of  the 
points  in  the  preparation  of  the  patient  which  are  of  importance  in  con- 
nection with  this  question  of  shock,  such  as  his  frame  of  mind,  a  good 
night's  rest  previous  to  the  operation,  and  the  administration  of  food.  Of 
especial  importance  is  the  nutrient  enema  of  brandy  and  peptonized  meat 
juice  given  half  an  hour  before  the  operation  (see  p.  83). 

An  essential  precautionary  point  is  to  take  measures  to  keep  up  the 
body  temperature.  The  operation  should  be  performed  in  a  warm  room 
free  from  draughts,  and  a  temperature  of  from  60°  to  80°  F.  should  be 
maintained.  This,  however,  is  not  of  itself  sufficient  in  bad  cases,  and 
the  best  plan  is  to  have  the  table  on  which  the  patient  is  lying  kept  at 
100°  to  105°  F.  by  means  of  warm  water.  In  some  operating  tables  this 
is  accomplished  by  having  the  top  of  the  table  composed  of  a  series  of 
tubes  through  which  hot  water  circulates  (see  Fig.  44),  but  this  necessitates 
a  special  table.  An  equally  good  plan  is  to  have  a  large  copper  tray  about 
6  inches  deep,  and  5  feet  in  length,  with  a  metal  top,  and  tubes  at  the 
ends  for  the  entrance  and  exit  of  hot  water,  which  is  kept  circulating 
through  it  during  the  operation.  Where  this  is  not  available,  its  place 
may  be  supplied  by  a  water-bed  or  large  water-pillow  filled  with  water  at 
a  temperature  of  110°  F.  The  latter  is  especially  good  in  cases  of  opera- 
tion upon  children,  although  from  the  movements  it  communicates  to  the 
patient  it  is  inferior  to  the  steadier  hot-water  table.  The  table  is  covered 
with  one  or  two  warm  blankets,  on  which  the  patient  lies,  and  the  aseptic 
towels  which  surround  the  area  of  operation  (see  Chap.  VIII.)  are  wrung 
out  of  hot  lotion  and  changed  at  intervals.  Where  the  arrangement  above 
described  is  not  available,  the  room  should  be  kept  as  warm  as  one  can 
work  in.  All  lotions  used  during  the  operation  should  be  at  about  a 
temperature  of  100°  F.  In  abdominal  operations,  if  coils  of  intestine 
escape  they  should  at  once  be  replaced,  and  if  it  be  necessary  to  keep 
them  outside  the  body  they  should  be  covered  with  warm  aseptic  cloths 
or  sponges  frequently  renewed.  Several  india-rubber  hot  water  bottles 
should  be  placed  about  the  patient,  taking  care  of  course  to  have  them 
well  covered  with  flannel  so  as  not  to  burn  him. 

Rapidity  of  operation  is  also  important  in  cases  where  shock  is  likely 
to  occur.  The  steps  of  the  operation  should  be  carefully  planned  before- 
hand, and  all  necessary  preparations  made  before  the  anaesthetic  is 
administered,  so  that  no  time  is  lost  afterwards.  Where  it  is  important 
to  reduce  the  time  that  the  patient  is  under  the  anaesthetic  to  a  minimum, 
all  preliminaries,  such  as  shaving,  purification  of  the  skin,  arrangement  of 
aseptic  towels,  etc.,  should  be  carried  out  before  the  anaesthetic  is  com- 


140 


WOUNDS. 


menced.  Loss  of  blood  should  also  be  avoided  as  far  as  possible.  The 
management  of  the  anaesthetic  has  been  specially  referred  to  in  the  section 
dealing  with  anaesthetics  (Chap.  V.). 


FIG.  44. — HOT-WATER  OPERATING  TABLE.  The  hot  water  circulates  through  the 
tubes,  of  which  the  entrance  and  exit  taps  are  shown.  The  cover  above  serves  to  diffuse 
the  heat  uniformly.  This  form  of  table  has  the  great  advantage  that  the  pelvis  can  be 
raised  (e.g.  when  Trendelenburg's  position  Ls  required)  without  interfering  with  the  hot- 
water  circulation. 

Of  the  very  greatest  value  in  the  prevention  or  diminution  of  shock  is 
the  administration  of  strychnine  before  the  commencement  of  the  operation. 
In  the  case  of  an  adult,  a  thirtieth  of  a  grain  should  be  injected  sub- 
cutaneously  just  before  the  operation,  or  while  the  patient  is  being  placed 
under  the  anaesthetic ;  and  during  the  course  of  the  operation,  if  the 
pulse  is  beginning  to  fail,  a  second  injection  of  a  sixtieth  of  a  grain  may 
be  administered.  It  is  of  the  greatest  importance  to  give  the  strychnine 
before  the  occurrence  of  shock,  for  when  shock  is  once  established  remedies 
are  of  little  avail,  and  recovery  mainly  depends  on  the  patient's  recupera- 
tive power.  Death  occurs  partly  from  the  severity  of  the  shock  (the  nerve 
centres  being  unable  to  regain  their  power)  and  partly  from  its  duration. 
Where  the  depression  is  long  continued,  and  the  circulation  consequently 
extremely  feeble,  clots  are  apt  to  form  in  the  pulmonary  artery,  and  recovery 
is  then  out  of  the  question. 


SHOCK.  141 

(b)  When  established. — When  shock  is  established  vigorous  measures 
must  be  adopted  to  combat  it.  In  the  first  place,  warmth  is  of  the  very 
highest  importance;  all  wet  cloths  should  be  removed  and  the  patient  wrapped 
up  in  warm  blankets,  outside  which  hot  bottles  are  placed;  benefit  will 
also  be  obtained  by  chafing  the  extremities  and  the  abdomen.  He  should 
be  put  to  bed  as  rapidly  as  possible  and  laid  quite  flat  with  only  a  thin 
bolster  beneath  the  head,  the  foot  of  the  bed  being  raised  about  6  inches 
so  as  to  favour  the  flow  of  blood  to  the  brain,  and  he  should  be  kept  as 
still  as  possible  so  as  not  to  exhaust  the  heart.  Free  stimulation  is  also 
important;  perhaps  the  most  rapid  stimulant  is  ether  injected  subcutane- 
ously  in  doses  of  from  20  to  30  minims.  The  point  of  the  needle  used  for 
injecting  the  ether  should  be  buried  in  the  muscle,  for  if  a  large  quantity 
be  injected  subcutaneously  sloughing  of  the  skin  may  occur.  The  ether 
may  be  repeated  in  15  or  20  minutes  if  necessary,  and  brandy  also  may 
be  injected  in  the  same  quantity  still  more  frequently.  Tincture  of  musk, 
in  doses  of  from  20  minims  to  a  drachm,  is  much  employed  on  the 
Continent,  but  it  must  be  freshly  prepared,  as  otherwise  it  is  very  apt  to 
contain  septic  organisms.  Stimulants  should  also  be  administered  by  the 
rectum  in  the  form  of  a  hot  nutrient  enema  containing  half  an  ounce  of 
brandy  (see  p.  83),  and  it  may  be  advisable  to  give  this  during  the 
course  of  the  operation  if  signs  of  severe  shock  appear.  Of  drugs,  the 
only  ones  that  are  of  any  avail  are  strychnine  and  digitaline,  a  thirtieth  of 
a  grain  of  strychnine  (or  a  sixtieth  if  it  has  been  already  twice  admin- 
istered during  the  course  of  the  operation  as  before  directed),  combined 
with  a  hundredth  of  a  grain  of  digitaline.  This  may  be  repeated  every 
hour  if  necessary  for  three  or  four  doses. 

Some  authorities  lay  much  stress  upon  the  value  of  transfusion,  which 
is  performed  as  described  on  p.  136.  The  effect  upon  the  pulse  and  the 
breathing  should  be  carefully  watched,  and  the  injection  continued  until 
the  pulse  is  felt  to  become  full,  regular,  and  approaching  its  normal  rate. 
For  this  purpose  at  least  two  or  three  pints,  or  even  more,  of  the  saline 
solution  will  be  required.  Care  should  be  taken  to  keep  up  the  tem- 
perature of  the  fluid. 

In  cases  where  this  transfusion  is  done  chiefly  for  loss  of  blood,  the 
results  are  doubtless  often  striking  and  most  satisfactory,  one  injection  being 
sufficient  to  tide  the  patient  over  his  danger.  Where,  however,  it  is  per- 
formed for  pure  shock  the  effect,  although  good,  is  often  only  temporary, 
and  after  the  lapse  of  from  a  half  to  three  hours  the  symptoms  of  shock 
begin  to  reassert  themselves.  Under  these  circumstances  it  may  be  neces- 
sary to  repeat  the  injection,  and  cases  have  occurred  where  this  had  to  be 
done  a  third  or  even  a  fourth  time.  The  effect  of  this  is,  however,  that 
the  dilution  of  the  blood  may  be  so  extreme  as  to  produce  imperfect  aeration 
in  the  lungs,  and  sometimes  severe  dyspnoea  may  result.  If  this  be  the 
case  the  operation  must  be  stopped,  and  reliance  placed  upon  rectal 
injections  and  the  administration  of  stimulants.  The  method  of  transfusion 


1 42  WOUNDS. 

as  a  treatment  for  profound  shock,  although  it  is  worth  a  trial  in  severe 
cases,  has  not  in  our  hands  proved  so  satisfactory  as  the  writings  of  some 
surgeons  might  have  led  us  to  expect. 

Where  the  case  is  one  of  pure  shock  the  further  dilution  of  the  blood 
can  hardly  be  expected  to  aid  the  recovery  of  the  nerve  centres.  A  better 
method  is  to  inject  the  saline  solution  into  the  rectum,  and  the  advantage 
of  this  plan  is  that  dilution  of  the  blood  does  not  occur  so  rapidly. 
Where  a  nutrient  enema  has  been  administered,  half  an  hour  or  an  hour 
must,  however,  be  allowed  to  elapse  before  the  saline  solution  is  injected. 
In  pure  shock  stimulants  are  of  much  importance,  but  where  there  is 
much  haemorrhage  the  saline  solution  is  of  more  immediate  value,  and 
therefore  an  enema  of  one  to  two  pints  should  be  given  at  once,  and  re- 
peated in  an  hour  if  necessary. 

Influence  of  pain  on  shock. — A  very  difficult  but  at  the  same  time  a 
very  important  question  is  how  far  pain,  when  severe,  keeps  up  the  shock, 
and  to  what  extent  anodynes  may  be  administered  with  the  view  of  relieving 
it.  There  can  hardly  be  any  doubt  that  prolonged  pain  will  cause  exhaustion 
of  the  nervous  system,  and  thus  prolong  or  even  set  up  shock,  and  it  is 
therefore  of  importance  to  diminish  it  if  possible.  An  injection  of  morphine 
before  the  patient  comes  round  from  the  anaesthetic  may  diminish  shock 
to  some  extent,  but  when  once  shock  is  established  morphine  alone  is  apt 
to  cause  a  great  deal  of  depression.  The  addition  of  atropine  to  some 
extent  removes  this  objection,  and  therefore  where  there  is  much  pain  a 
subcutaneous  injection  of  a  quarter  of  a  grain  of  morphine  with  yi^th  of 
a  grain  of  atropine  is  advisable. 


Entry  of  air  into  veins. 

In  connection  with  bleeding  from  wounds,  we  may  here  consider  the 
question  of  the  entrance  of  air  into  veins,  which  often  leads  to  very  serious 
results.  This  accident  is  especially  apt  to  happen  in  operations  about 
the  root  of  the  neck  on  account  of  the  proximity  of  the  heart,  and  the 
fact  that  the  veins  pass  through  rigid  openings  in  the  deep  fascia  of  the 
neck.  In  these  operations,  if  a  vein  be  opened,  and  not  immediately 
occluded,  air  is  apt  to  be  sucked  in  through  the  proximal  end  of  the 
vessel,  during  inspiration,  and  this  will  give  rise  to  very  serious  symptoms, 
more  especially  to  embarrassment  of  the  pulmonary  circulation.  The  right 
side  of  the  heart  becomes  full  of  blood,  which  is  frothy  from  admixture 
with  air,  and  this  material  is  not  readily  driven  on  into  the  pulmonary 
art  iry,  and  in  consequence,  in  some  cases  immediate  death  is  the  result. 
In  other  cases  where  less  air  enters,  death  does  not  occur  so  suddenly. 
The  patient  cries  and  gasps,  he  struggles  for  breath,  and  becomes  blue 
from  non-oxygenation  of  his  blood. 

Where   the   amount    of    air   sucked   in   is   quite   small   the   obstruction 


SYNCOPE. 


'43 


may  be  overcome  and  the  circulation  re-established.  In  these  cases,  it  is 
not  uncommon  for  a  small  patch  of  pneumonia  to  form  in  the  lungs  where 
the  bubbles  of  air  and  blood  have  collected.  The  accident  is  so  sudden 
and  dangerous,  that  the  possibility  of  its  occurrence  should  always  be  borne 
in  mind  by  surgeons,  especially  in  operating  about  the  neck,  and  if  veins 
must  be  divided,  they  should  if  possible  be  clamped  before  division;  if,  how- 
ever, this  be  not  done,  the  proximal  end  should  be  at  once  compressed  by 
the  finger,  so  as  to  prevent  the  accidental  entrance  of  air,  and  a  clamp  put 
on  as  quickly  as  possible.  The  operation  should  not  be  proceeded  with 
until  the  divided  ends  of  the  vein  have  been  closed.  The  accident  is 
more  especially  likely  to  happen  where  veins  are  only  partially  divided, 
and  where  the  rent  is  made  during  the  surgeon's  manipulations,  as  for 
instance  in  pulling  forward  the  thyroid  gland  during  thyroidectomy. 

Treatment. — If,  during  the  course  of  an  operation,  symptoms  arise  which 
show  that  air  has  entered  the  veins,  the  wound  should  be  flooded  with 
lotion  immediately  the  characteristic  hissing  or  sucking  noise  is  heard,  with 
a  view  of  preventing  further  entrance  of  air ;  and  when  this  has  been 
done,  the  next  point  is  to  make  an  effort  to  force  the  air  out  again  from 
the  vessels  in  the  chest.  This  is  best  done  by  forcibly  compressing  the 
chest,  while  at  the  same  time  pressure  on  the  vein  is  relaxed  so  as  to 
allow  the  air  and  frothy  blood  to  be  poured  out  through  its  open  end; 
on  allowing  the  chest  to  expand  the  vein  is  again  compressed,  and  so  on. 
Another  thing  that  may  be  done,  is  to  aspirate  the  vein,  a  small  tube 
such  as  a  sterilized  catheter  being  introduced  into  it,  the  end  of  the 
vein  compressed  tightly  around  it,  and  then  an  attempt  made  to  suck  the 
froth  out.  As  a  rule,  however,  where  a  large  quantity  of  air  has  passed 
in,  death  is  immediate,  and  it  is  quite  impossible  to  save  the  patient. 


Syncope. 

Syncope  is  a  not  infrequent  complication  of  operations.  By  the  term  is 
meant  complete  arrest  of  the  heart's  action,  accompanied  by  loss  of  conscious- 
ness. This  is  in  contrast  to  shock  where  the  loss  of  consciousness  is  not 
complete,  and  where  the  pulse  is  always  to  be  felt  although  it  is  often  very 
feeble.  Syncope  or  faintness  may  result  from  sudden  loss  of  blood;  from 
withdrawal  of  blood  to  another  part,  as  in  tapping  the  abdomen  for 
ascites ;  or  reflexly  from  sudden  nervous  shock,  especially  if  the  patient  be 
not  fully  anaesthetised.  Where  the  patient  is  not  under  an  anaesthetic, 
syncope  is  usually  preceded  by  vertigo,  tinnitus,  nausea,  and  imperfect 
sight,  and  these  symptoms  are  followed  by  arrest  of  the  heart's  action, 
cessation  of  bleeding,  marked  pallor,  dilated  pupils,  cold  sweat  over  the 
forehead,  cold  extremities,  respirations  feeble  or  absent,  and  total  loss  of 
consciousness.  The  condition  is  due  to  a  deficient  supply  of  blood  to 
the  brain.  Except  in  extreme  cases,  the  arrest  of  the  heart's  action  is 


144 


WOUNDS. 


only  momentary,  and  recovery  is  indicated  by  sighing  and  gasping  respira- 
tions, reappearance  of  the  pulse,  and  gradual  return  of  consciousness. 

In  the  treatment  of  syncope  it  must  be  borne  in  mind  that  the 
symptoms  are  essentially  due  to  absence  of  blood  from  the  brain,  and 
steps  should  be  taken  to  remedy  this.  Before  syncope  is  completely  estab- 
lished it  is  often  sufficient  to  depress  the  patient's  head  well  between  his 
knees,  so  that  it  is  at  a  considerably  lower  level  than  the  heart,  and  under 
these  circumstances  the  face  will  often  flush  and  the  feeling  of  faintness  will 
pass  off.  Above  all  things,  when  syncope  is  established,  the  patient's  head 
must  be  lowered  ;  there  is  nothing  more  dangerous  than  to  leave  the  patient 
sitting  up,  or  with  his  head  reclining  upon  a  pillow ;  the  heart  may  not 
act  again  in  time  to  supply  blood  to  the  vital  centres  while  recovery  can 
take  place.  It  is  well  also  to  elevate  the  legs  so  that  any  blood  present 
in  the  lower  extremities  may  run  back  into  the  larger  vessels.  The  chest 
also  must  be  free,  and  there  must  be  nothing  tight  around  the  neck. 
Sudden  shocks  to  the  external  surface  will  set  up  the  heart's  action  again, 
the  most  favourite  plan  being  to  bare  the  chest  and  dash  cold  water  over 
it,  or  slap  it  with  wet  towels.  Cold  water  dashed  over  the  head  has 
similarly  a  good  effect.  The  Faradic  current  may  also  be  employed  to 
the  region  of  the  phrenics  so  as  to  produce  contraction  of  the  diaphragm ; 
this  is  best  done  by  means  of  two  small  moistened  electrodes  about 
the  size  of  a  shilling,  connected  with  an  induction  coil,  which  are  pushed 
forwards  beneath  the  posterior  edge  of  the  sterno-mastoids  just  above  the 
clavicle  on  each  side,  and  the  current  then  made  and  broken  from  15 
to  30  times  per  minute.  Each  closure  of  the  current  causes  an  inspiration, 
followed  by  an  expiratory  effort.  Direct  stimulation  to  the  region  of  the 
heart  seems  to  do  no  good  and  may  be  actually  harmful.  The  strength 
of  the  current  should  be  from  5  to  15  milliamperes. 

There  must  be  also  plenty  of  fresh  air ;  no  crowd  should  be  allowed 
to  gather  around  the  patient,  and  when  he  is  able  to  swallow,  a  little  brandy 
and  water,  or  other  stimulant,  will  aid  the  recovery.  When  syncope  occurs 
during  the  course  of  an  operation,  the  patient  should  be  pulled  up  to  the 
end  of  the  table  and  his  head  allowed  to  hang  over  it,  or  the  foot  of  the 
table  may  be  tilted  up.  Artificial  respiration  must  be  employed,  and  slap- 
ping the  chest  with  wet  towels,  and  the  application  of  the  Faradic  current 
to  the  region  of  the  phrenic  nerves,  as  just  described. 


AFTER-TREATMENT  OF  OPERATIONS. 

When  no  collapse  is  present,  the  patient  should  be  put  to  bed  as 
quickly  and  gently  as  possible,  and  wrapped  up  in  warm  blankets.  In 
most  cases  he  should  lie  on  his  back,  and  where  possible  with  only  a  thin 
bolster  under  the  head.  The  room  should  be  rapidly  cleared  and  darkened, 
and  the  patient  left  perfectly  quiet.  If  this  be  done  the  narcosis  may  pass 


AFTER-TREATMENT   OF   OPERATIONS.  145 

into  ordinary  sleep,  which  may  last  an  hour  or  two,  and  in  that  case  the 
patient  may  have  no  pain  at  all  when  he  wakes  up ;  at  any  rate  the  worst 
of  the  pain  will  have  passed  off,  and  the  sickness  will  not  be  so  great. 

Feeding. — Neither  food  nor  drink  should  be  given  for  three  or  four 
hours  after  the  operation ;  at  most,  a  small  quantity  of  very  hot  water  or  a 
teaspoonful  of  brandy  and  water  if  absolutely  necessary.  At  the  end  of 
that  time,  if  the  patient  desire  food,  some  warm  beef-tea  may  be  given, 
and  after  about  six  hours,  if  there  be  no  sickness,  this  may  be  alternated  with 
milk  and  soda.  It  is  well  not  to  push  the  feeding  for  the  first  24  hours, 
unless  in  the  case  of  a  very  weakly  patient,  and  even  then  two  or  three 
nutrient  enemata  or  zyminized  suppositories  administered  at  intervals  of 
four  hours  are  better  than  feeding  by  the  mouth.  If  feeding  by  the  mouth 
be  commenced  too  soon,  or  pushed  too  energetically,  it  is  apt  to  bring  on 
serious  sickness.  For  the  treatment  of  vomiting  after  an  anaesthetic,  see 
p.  117.  If  there  be  much  pain,  a  quarter  of  a  grain  of  morphine  may  be 
injected  subcutaneously  soon  after  the  operation,  but  in  most  cases  it  is 
best  to  leave  the  patient  alone. 

The  patient  should  always  be  seen  on  the  evening  of  the  operation  in 
case  he  is  in  pain,  for  which  morphine  may  be  necessary;  in  case  any 
bandage  be  too  tight  and  require  cutting;  also  in  case  there  be  retention 
of  urine,  which  may  occur  not  only  after  rectal  and  perineal  operations, 
but  sometimes  in  other  cases.  Other  troubles  of  which  the  patient  may 
complain  are  the  occurrence  of  colicky  pains  and  pain  in  the  loins. 
Colicky  pains  are  not  uncommon,  more  especially  after  hernia  operations, 
and  if  they  occur  they  seldom  entirely  subside  until  the  bowels  have  acted. 
They  are,  however,  diminished  by  the  administration  of  opium.  Pain  in 
the  back  is  a  very  common  complaint  with  people  who  have  been  in 
vigorous  health  before  the  operation,  especially  where  the  operation  is 
prolonged,  and  where  the  patient  has  to  lie  on  his  back  afterwards.  This 
passes  off  in  24  or  36  hours,  but  while  it  lasts  it  causes  considerable  dis- 
comfort. A  pillow  or  an  india-rubber  hot  water  bottle  under  the  back 
relieves  it  to  some  extent,  and  where  we  expect  that  it  may  happen,  e.g.  in 
prolonged  operations,  it  is  well  to  place  a  pillow  under  the  loins  when  the 
patient  is  put  upon  the  operating  table. 

In  cases  where  asepsis  is  obtained,  the  patient  is  free  from  pain  by  the 
next  day  at  latest  and  rapidly  regains  his  normal  strength,  very  little 
further  attention  being  required.  If  the  operation  has  been  a  severe  one, 
it  may  be  well  for  48  hours  after  the  operation  to  keep  him  on  slops,  that 
is  to  say,  beef-tea,  chicken  broth,  milk,  a  little  champagne  or  other  stimulant, 
etc.,  and  then  on  the  third  day  to  commence  solid  food,  and  in  a  day  or 
two  to  let  him  have  his  ordinary  diet.  Where  the  operation  has  not  been 
severe,  and  there  has  been  no  sickness,  no  restriction  need  be  placed  on 
the  diet  after  the  first  24  hours. 

Aperients. — The  patient  is  seldom  quite  comfortable  until  the  bowels 
have  been  cleared  out,  and  this  should  generally  be  seen  to  on  the  second 

K 


146  WOUNDS. 

or  third  day  after  the  operation.  The  best  plan  is  the  administration  of  a 
dose  of  castor  oil  in  the  evening,  followed  by  a  seidlitz  powder  or  an 
enema  in  the  morning.  This,  of  course,  does  not  apply  to  such  operations 
as  those  upon  the  rectum,  etc.,  where  it  is  often  essential  to  keep  the 
bowels  confined  for  some  days.  Certain  special  points,  such  as  the  time  to 
allow  a  patient  to  get  up,  etc.,  will  be  noted  under  individual  operations. 


CHAPTER  VII. 

WOUNDS. 
MODES  OF  HEALING. 

IT  may  be  well,  before  discussing  the  treatment  of  wounds,  to  refer 
very  shortly  to  the  modes  in  which  they  heal.  There  are  five  methods 
by  which  healing  may  take  place,  namely :  healing  by  first  intention,  by 
blood  clot,  under  a  scab,  by  granulation,  and  by  union  of  granulations. 
The  particular  form  of  healing  which  occurs  depends,  in  the  first  place,  on 
whether  the  edges  of  the  wound  are  brought  together  or  remain  apart, 
and,  in  the  second  place,  on  whether  causes  of  suppuration  gain  access  to 
the  wound,  either  at  the  time  of  its  infliction  or  at  some  subsequent  period. 

The  immediate  result  of  the  infliction  of  a  wound  is  bleeding,  and  blood 
clot  forms  on  the  cut  surface.  When  this  clot  is  wiped  off  it  is  found  that 
exudation  is  taking  place  beneath  ;  in  other  words,  as  the  result  of  the 
irritation  of  the  knife  and  the  contact  of  foreign  bodies,  a  narrow  micro- 
scopic layer  of  inflammation,  going  on  as  far  as  the  end  of  the  first 
stage — namely,  exudation — has  been  set  up.  The  result  in  all  wounds, 
whatever  their  nature,  whether  the  edges  are  brought  together  or  not,  is 
that  lymph  (i.e.  coagulated  fibrin  entangling  white  corpuscles)  is  poured 
out  and  glazes  the  surface. 

Healing  by  "  First  intention." — Where  no  further  causes  of  inflam- 
mation come  into  play,  notably  where  no  bacteria  are  present,  this  lymph 
remains,  and  if  the  edges  of  the  wound  are  brought  into  apposition,  it 
glues  the  two  surfaces  together.  It  then  soon  becomes  infiltrated  with 
cells :  at  first  leucocytes,  and,  later  on,  larger  plasma  cells  pass  into  it. 
These  plasma  cells  apparently  feed  on  the  remains  of  the  white  corpuscles 
and  destroy  them,  and  they  themselves  enlarge,  become  spindle-shaped, 
and  form  young  fibrous  tissue.  The  result  is  that,  while  after  the  first 
24  hours  the  two  cut  surfaces  are  separated  by  a  layer  of  young  cells, 
in  the  course  of  three  or  four  days  the  cells  have  become  spindle-shaped 
and  some  of  them  are  already  forming  young  fibrous  tissue.  New  blood- 
vessels are  also  developed  very  much  in  the  same  manner  as  in  the 
embryo.  As  time  goes  on,  the  fibrous  tissue  between  the  two  cut  surfaces 


148  WOUNDS. 

becomes  more  perfect  and  contracts,  thus  shortening  the  incision  and 
temporarily  depressing  its  surface;  the  newly-formed  vessels  also  tend  to 
disappear.  Later  on  this  new  fibrous  tissue,  where  it  is  situated  in  the 
middle  of  fat,  becomes  itself  converted  into  areolar  tissue,  fat  cells  form 
in  it,  and  the  scar  becomes  looser. 

The  epithelial  cells  on  the  surface  begin  about  the  second  or  third 
day  to  multiply  and  spread  over  this  narrow  line  of  young  cellular  tissue, 
so  that,  in  most  cases,  at  the  end  of  the  fourth  or  fifth  day,  there  is  a 
continuous  layer  of  epithelium  from  one  edge  of  the  wound  to  the  other. 
This  process  is  termed  primary  union,  or  healing  by  first  intention,  and 
it  ought  to  be  aimed  at  in  all  cases,  because  in  connection  with  it  there 
is  no  general  disturbance,  no  fever,  and  no  septic  trouble,  while  the 
resulting  scar  is  small  and  after  a  time  almost  unnoticeable. 

Healing  by  blood  Clot. — Where  the  edges  of  the  wound  are  not  in 
apposition,  the  space  between  the  cut  surfaces  becomes  filled  with  coagulated 
blood,  whilst  the  surfaces  themselves  are  covered  with  lymph.  Under 
certain  circumstances,  where  no  further  causes  of  inflammation  come  into 
play,  this  blood  clot  remains  and  forms  a  mould  in  which  the  young  cells 
(the  plasma  cells)  develop  and  form  fibrous  tissue  and  fresh  blood-vessels. 
After  a  time,  when  nearly  the  whole  of  the  blood  clot  has  become  organized, 
epithelial  cells  begin  to  spread  over  this  imperfect  tissue  from  the  sides. 
In  the  case  of  small  wounds  it  is  often  found  at  the  end  of  about  14 
days  that  a  thin  layer  of  the  top  of  the  blood  clot  can  be  peeled  off, 
leaving  an  epithelium-covered  surface  beneath.  This  process  may  be  termed 
healing  by  blood  clot,  and  although  it  is  only  visible  when  the  edges  of 
the  wound  do  not  come  together,  it  occurs  to  a  greater  or  less  extent  in 
almost  all  wounds  of  any  depth,  because  the  deeper  parts  of  a  wound 
are  seldom  in  such  accurate  contact  that  only  a  thin  layer  of  lymph 
divides  them ;  where  there  is  any  appreciable  separation,  blood  clot  forms 
between  the  raw  surfaces,  and  undergoes  organization  in  the  manner  just 
described.  Hence,  even  in  wounds  that  heal  by  first  intention,  that  process 
as  a  rule  only  takes  place  towards  the  surface,  while  the  deeper  parts 
heal  by  blood  ck>t. 

Healing  under  a  scab. — The  process  of  healing  by  scabbing  is  prac- 
tically the  same  as  healing  by  a  thin  layer  of  blood  clot.  The  superficial 
layer  of  lymph  and  blood  dries  up  and  forms  a  scab,  which  protects  the 
surface  of  the  wound  from  irritation,  and  organization  goes  on  in  the  thin 
layer  of  lymph  beneath,  while  epithelial  cells  spread  in  underneath  the  scab. 

Healing  by  granulation. — Where  wounds  are  irritated,  or  where 
sepsis  is  present,  healing  takes  place  by  granulation.  Where  this  happens 
the  edges  of  the  wound  have  either  not  been  brought  together,  or,  if  they 
have,  union  by  first  intention  has  failed,  owing  usually  to  the  occurrence 
of  sepsis.  As  in  both  the  preceding  cases,  effusion  of  lymph  occurs  as  the 
first  change,  but  the  process  of  inflammation  does  not  stop  there.  Since 
the  causes  of  irritation  continue  to  act,  the  inflammation  goes  on  to  the 


MODES   OF    HEALING. 


149 


second  stage,  namely,  granulation,  so  that  all  the  structures  exposed  in 
the  wound  become  converted  into  granulation  tissue,  and  the  original 
tissue  disappears.  This  granulation  tissue  soon  becomes  arranged  in  the 
form  of  little  rosy  buds,  termed  granulations,  which  on  microscopical 
examination  are  seen  to  be  composed  of  embryonic  cells  with  numerous 
young  blood-vessels.  These  granulations  continue  to  grow  and  ultimately 
fill  up  the  wound,  and  when  they  are  nearly  on  a  level  with  the  skin, 
epithelium  begins  to  spread  over  their  surface. 

While  this  process  is  going  on,  the  cells  of  the  granulation  tissue  in  the 
deeper  parts  of  the  wound,  being  protected  from  irritation  by  the  granula- 
tions on  the  surface,  develop  into  young  fibrous  tissue,  and  the  blood- 
vessels become  obliterated  in  large  numbers.  This  young  fibrous  tissue  at 
once  begins  to  contract,  and  this  contraction  results  in  the  drawing  together 
of  the  edges  of  the  wound,  so  that,  even  before  the  spread  of  epithelium 
has  commenced  at  the  surface,  the  wound  may  be  very  much  smaller  than 
it  was  when  first  made. 

When  the  young  epithelial  cells  begin  to  spread  over  the  surface,  a 
delicate  red  line  is  found  around  the  edge  of  the  sore,  because  at  first 
the  epithelial  cells  are  young,  transparent,  and  only  in  a  single  layer, 
and  therefore  they  allow  the  red  colour  of  the  granulation  tissue  to  show 
through.  At  a  later  period  the  epithelium  becomes  thicker,  and  a  bluish 
appearance  is  the  result ;  still  later,  when  the  epithelium  has  been  formed 
for  some  time,  the  thick  layer  on  the  surface  becomes  macerated  and 
white,  like  the  skin  of  a  washerwoman's  hand,  and  there  is  a  white  line 
formed.  Thus,  in  a  healing  wound,  we  have  three  zones — an  outer 
white  line  shading  off  into  a  blue  one,  and  that  again  shading  off  into  a 
delicate  pink  one.  In  many  cases  this  pink  line  is  not  noticeable  until 
the  wound  has  been  dried,  when  it  will  be  seen  that,  while  the  granulations 
on  the  surface  of  the  unhealed  part  begin  to  ooze  and  become  moist,  the 
red  line  at  the  edge  of  the  wound  remains  dry.  The  detection  of  this  red 
line  is  of  great  importance,  because  it  implies  that  healing  is  in  active 
progress. 

The  ultimate  stages  of  healing  by  granulation  consist  in  the  new  epithe- 
lium becoming  thicker  and  thicker  over  the  surface,  so  that  for  some  weeks 
epithelial  scales  are  constantly  forming.  Later  on  the  wound  contracts,  and 
this  contraction  may  lead  to  very  serious  deformity.  The  structure  of  the 
scar  undergoes  continued  alteration  until  ultimately  it  is  composed  of  a 
mass  of  fibrous  tissue  covered  with  epithelium,  and  containing  very  few 
blood-vessels ;  but  there  is  no  development  in  it  of  the  special  structures 
of  the  skin,  such  as  hairs  and  sebaceous  or  sweat  glands. 

During  the  process  of  healing  by  granulation,  the  patient  is  exposed  to 
the  risk  of  severe  local  and  general  troubles  arising  from  the  various 
infective  diseases  due  to  bacteria,  which  may  gain  entrance  through  the 
open  wound.  These  will  be  described  in  their  proper  place.  In  any 
case,  unless  the  wound  be  aseptic  or  very  small,  there  is  a  certain  amount 


150  WOUNDS. 

of  fever  ("traumatic  fever")  during  the  period  of  the  formation  of  the 
granulations,  due  to  the  absorption  of  poisonous  products  from  the  decom- 
position in  the  wound.  When  granulation  is  complete,  that  is  to  say, 
about  the  third  or  fourth  day,  the  temperature  falls  and  the  fever  disappears, 
because  the  granulations  do  not  permit  absorption  of  these  poisonous 
products. 

Apart  from  the  danger  of  sepsis,  a  drawback  to  this  mode  of  healing 
is  that  the  scar  is  larger  than  after  healing  by  first  intention,  and  the 
deformity  due  to  the  contraction  of  the  scar  is  sometimes  very  serious ; 
it  is  evident,  therefore,  that  healing  by  granulation  is  not  such  a  desirable 
process  as  is  union  by  first  intention. 

Healing  by  union  Of  granulations. — Lastly,  there  is  another  mode 
of  healing  which  was  at  one  time  much  encouraged,  namely,  healing  by 
union  of  granulations.  Here  the  edges  of  the  wound  are  not  brought 
together  in  the  first  instance,  but  are  kept  apart  with  dressings  until  both 
surfaces  are  granulating,  and  then,  when  granulation  is  complete,  the 
surfaces  are  purified  and  brought  together.  The  result  is  that  over  a  con- 
siderable area  these  granulating  surfaces  adhere,  and  union  occurs  rapidly ; 
but  the  risks  attendant  on  healing  by  granulation,  to  which  reference  has 
just  been  made,  apply  to  this  method  of  healing  also.  It  is  not  a  mode 
that  should  be  deliberately  chosen  when  other  methods  are  available, 
but  it  is  well  to  bear  in  mind  that  granulating  wounds  may  unite  if 
their  edges  are  brought  together. 

Conditions  inimical  to  healing  by  first  intention. — In  order  to 
obtain  healing  by  first  intention  (which  should  always  be  aimed  at  in 
incised  wounds),  it  is  essential,  in  the  first  place,  to  bring  the  edges  of 
the  wound  together,  and,  in  the  second  place,  to  avoid  anything  which  may 
lead  to  inflammation.  Among  the  minor  conditions  which  tend  to  prevent 
union  by  first  intention  are,  firstly,  mechanical  irritation  of  the  part,  more 
especially  in  the  form  of  movement  either  of  the  part  itself  or  of  the 
muscles  beneath  it ;  secondly,  the  presence  of  too  tight  stitches ;  thirdly, 
the  irritation  of  dressings,  or  of  the  chemical  substances  contained  in 
them,  or  used  as  lotions.  The  most  common  cause,  however,  which  leads 
to  the  failure  of  union  by  first  intention  or  by  blood  clot,  and  which 
exposes  the  patient  to  the  various  serious  risks  which  will  afterwards  be 
mentioned,  is  the  entrance  of  micro-organisms  and  their  growth  either  in 
the  material  on  the  surface  of  the  wound  or  in  the  tissues  themselves. 
The  organisms  which  act  in  this  way  are  essentially  the  pyogenic  organisms, 
and  they  consist  of  various  kinds  of  micrococci,  known  as  the  pyogenic 
cocci,  the  chief  of  them  being  the  staphylococcus  pyogenes  aureus,  staphy- 
lococcus  pyogenes  albus,  and  streptococcus  pyogenes.  These  organisms 
growing  in  a  wound  peptonize  the  materials  on  the  surface,  and  so  lead  to 
the  destruction  of  the  original  tissue,  while  they  produce  chemical  substances 
of  great  potency,  which  act  locally  by  causing  first  granulation,  and  subse- 
quently suppuration,  and,  generally,  by  setting  up  febrile  disturbance. 


MODES   OF    HEALING.  151 

These  micro-organisms  are  normally  present  in  most  cases  on  the  surface 
of  the  skin  and  mucous  membranes,  more  particularly  in  parts  where  the 
skin  is  moist,  as,  for  example,  in  the  perineum,  the  axilla,  between  the 
toes,  in  the  dirt  under  the  nails,  and  so  forth.  They  grow  in  the  old 
epithelium  on  the  surface  of  the  skin  around  the  hairs,  and  they  also 
appear  to  penetrate  into  the  orifices  of  the  sebaceous  and  hair  follicles. 
They  vary  in  virulence,  and  the  different  kinds  vary  also  in  their  mode  of 
action.  For  example,  the  staphylococci  seem  especially  to  cause  the  circum- 
scribed abscesses,  whereas  the  streptococci  creep  among  the  tissues,  causing 
diffuse  cellulitis,  and  gain  access  to  the  blood  stream  and  set  up  pysemia. 

The  great  object  of  wound  treatment  is,  therefore,  to  prevent  the  entrance 
of  these  organisms  into  the  wound,  or,  in  cases  where  this  is  impossible — 
as,  for  example,  in  operations  about  the  mouth  or  the  rectum — to  interfere 
with  their  growth,  and  thus  to  minimise  their  evil  effects  as  far  as  possible. 
With  the  view  of  preventing  the  entrance  of  these  organisms  into  the 
wound,  various  antiseptics  must  be  employed.  Various  substances  are  now 
known  which  kill  the  organisms,  some  of  them  with  rapidity,  and,  fortunately 
for  us,  the  organisms  which  cause  the  mischief  in  wounds  are,  with  few 
exceptions  (notably  the  tetanus  bacillus),  non-spore-bearing,  and  hence 
are  very  readily  killed  even  by  dilute  antiseptic  solutions.  A  5  per  cent, 
carbolic  acid  solution  will  destroy  these  pyogenic  cocci  in  a  few  seconds, 
provided  always  that  it  is  enabled  to  gain  proper  access  to  them ;  similarly 
a  1-2000  sublimate  solution  will  act  very  quickly.  It  is  essential,  how- 
ever, that  these  solutions  be  able  to  gain  free  access  to  the  organisms. 
It  must  be  remembered,  with  regard  to  these  and  some  other  antiseptics, 
that  they  coagulate  albumen,  and  thus  organisms  protected  by  this  layer 
of  coagulum  may  escape  their  action.  Heat  of  course  is  a  most  potent 
agent  in  the  destruction  of  bacteria,  both  dry  heat  at  a  temperature  of 
130°  C.  (280°  F.),  and  moist  heat  in  the  form  of  water  at  the  boiling 
point.  To  boil  instruments,  or  any  other  materials  for  a  sufficient  time, 
will  thoroughly  disinfect  them.  This  point  will  be  more  fully  referred  to 
in  dealing  with  the  disinfection  of  instruments  (see  Chap.  VIII.). 


CHAPTER   VIII. 

WOUNDS. 
TREATMENT   OF   INCISED  WOUNDS. 

CLASSIFICATION    OF    INCISED    WOUNDS.— There    are    two 

great  classes  of  incised  wounds,  those  made  by  the  surgeon,  and  those 
inflicted  before  the  patient  is  seen  by  him.  Wounds  made  by  the  surgeon 
may  be  again  subdivided  into : — (a)  those  made  through  unbroken  skin 
and  not  communicating  with  mucous  surfaces ;  (b)  those  made  in  connection 
with  previously  existing  sinuses  or  suppurating  deposits,  or  communicating 
with  some  mucous  canal.  The  importance  of  this  subdivision  is  that,  while 
it  is  a  comparatively  easy  matter  to  exclude  micro-organisms  from  wounds 
of  the  first  class,  it  is  either  very  difficult  or  altogether  impossible  to  do 
so  in  the  second  variety;  the  treatment  in  the  latter  must  therefore  be 
directed  towards  minimising  the  ill  effects  produced  by  the  organisms  after 
they  have  gained  entrance. 

WOUNDS   MADE   BY   THE   SURGEON   THROUGH    UNBROKEN   SKIN. 

It  is  clear  from  what  has  gone  before  that  the  point  to  be  aimed  at  here 
is  healing  by  first  intention.  If  this  be  obtained,  there  is  rapid  recovery 
and  a  delicate  scar  is  left,  which  later  on  becomes  practically  invisible, 
while  the  general  septic  conditions  or  the  local  inflammatory  troubles  which 
may  occur  if  union  by  first  intention  be  not  obtained,  are  avoided. 

The  conditions  which  favour  healing  by  first  intention  have  already 
been  referred  to  (see  p.  150);  of  these,  one  that  is  absolutely  essential 
is  the  asepsis  of  the  wound ;  in  addition  to  this,  however,  care  has  to  be 
taken  to  bring  the  edges  of  the  wound  into  accurate  apposition.  Besides 
this,  causes  of  unrest,  such  as  movement,  irritation  by  the  dressings,  etc., 
must  be  avoided.  We  shall  consider  these  latter  conditions  first. 

Apposition  of  the  Edges. — The  edges  of  the  wound  must  be  in  accurate 
apposition  ;  if  they  are  not  in  contact  with  one  another,  an  interval  is  left 
which  becomes  filled  up  with  blood  clot,  and  although  healing  by  blood 
clot  will  occur  if  the  wound  be  aseptic,  it  is  not  so  good  as  union  by  first 


TREATMENT   OF    INCISED   WOUNDS.  153 

intention.  In  placing  the  edges  of  the  wound  in  apposition,  care  should 
be  taken  to  see  that  one  edge  is  not  on  a  higher  level  than  the  other. 
Should  this  occur  to  a  very  slight  extent  it  will  not  matter,  except  in  so 
far  that  the  subsequent  cicatrix  is  not  a  fine  delicate  line,  but  shows  a 
definite  ridge.  If,  however,  there  be  any  marked  difference  in  level  be- 
tween the  edges,  and  more  especially  if  the  raw  surface  of  the  one  side 
chance  to  lie  in  contact  with  the  cutaneous  surface  of  the  other,  healing 
of  the  overlapping  raw  surface  will  not  take  place  although  the  deeper 
parts  will  unite  satisfactorily  enough.  It  is  a  curious  fact  that  epithelium 
will  not  spread  over  a  raw  surface  which  is  lying  in  contact  with  epithelium- 
covered  skin,  and  where  an  overlapping  of  the  kind  alluded  to  is  present, 
it  is  necessary,  in  order  to  obtain  proper  healing,  to  pare  away  the  inverted 
or  overlapped  edge  of  the  skin,  and  thus  to  have  two  raw  surfaces  opposed 
to  each  other. 

Approximation  of  Deeper  Structures. — When  a  wound  has  to  be 
closed  it  is  important  to  remember  that  its  deeper  parts  must  be  approxi- 
mated as  well  as  its  cutaneous  edges.  For  this  purpose  some  surgeons 
employ  deep  stitches  and  then  put  in  superficial  ones  to  bring  together  the 
skin  and  the  more  superficial  structures;  this  is  however  hardly  necessary 
in  the  large  majority  of  cases.  By  properly  applied  pressure  outside 
the  wound  (see  p.  170),  it  is,  as  a  rule,  quite  possible  to  bring  the  deeper 
parts  sufficiently  together,  and  stitches  need  only  be  employed  for  the 
approximation  of  the  edges  of  the  skin. 

Sutures. — The  choice  of  the  particular  material  that  is  to  be  used  for 
stitches  is  determined  by  the  asepticity  of  the  wound  and  the  amount  of 
tension  upon  its  edges.  As  we  are  now  dealing  only  with  aseptic  wounds, 
we  have  merely  to  consider  what  materials  are  suitable  for  stitches  in 
(a)  those  where  there  is  no  tension  on  the  edges;  (b)  those  where  the  tension 
is  very  great,  and  (c)  those  where  it  is  only  moderate  in  amount.  It  is  also 
well  to  bear  in  mind,  more  particularly  in  connection  with  wounds  on  exposed 
parts,  such  as  the  face,  neck,  etc.,  that  where  there  has  been  healing  by  first 
intention  more  unsightliness  is  produced  by  the  stitch  marks  than  by 
the  cicatrix  itself;  therefore,  under  these  circumstances,  the  avoidance  of  stitch 
marks  is  a  matter  of  considerable  importance.  Whatever  be  the  material 
used  for  stitches,  it  should  be  kept  in  a  1-20  carbolic  lotion  for  at  least 
several  hours  before  the  operation,  and  then  washed  in  1-2000  sublimate 
solution  immediately  before  it  is  used. 

(a)  Where  there  is  no  tension. — Where  there  is  no  tension  on  the  edges 
of  the  wound,  and  where  as  delicate  a  scar  as  possible  is  desired,  as  in 
operations  upon  the  face  and  neck,  the  finest  material  only  should  be 
used,  and  the  stitches  should  not  be  put  closer  together  than  is  absolutely 
necessary  to  keep  the  edges  in  contact ;  and  further,  they  should  be  inserted 
as  close  as  possible  to  the  line  of  incision.  Under  these  circumstances 
fine  horse-hair  is  probably  the  best  material  to  employ.  The  size  of  the 
stitch  marks  may  be  still  further  reduced  if  a  fine  Hagedorn's  needle  be 


154  WOUNDS. 

employed.  This  form  of  needle  is  flattened  from  side  to  side,  so  that  it 
makes  its  skin  puncture  at  right  angles  to  the  edge  of  the  wound,  and  as 
the  stitch  is  pulled  tight,  its  tendency  is  to  close  the  small  hole,  whereas 
with  the  ordinary  curved  needle,  which  makes  an  incison  parallel  to  the 
edge  of  the  wound,  the  effect  of  tightening  the  suture  is  to  enlarge  the 
incision  and  consequently  to  leave  a  larger  scar. 

How  to  avoid  Stitch  Marks. — In  many  cases  of  small  wounds,  such  as 
those  upon  the  face,  it  is  possible,  by  taking  a  little  trouble,  to  avoid  stitch 
marks  entirely.  The  best  plan  is  to  approximate  the  deeper  part  of  the 
dermis  by  buried  sutures,  and  when  this  is  done  the  superficial  part  can 
be  brought  accurately  together  by  strips  of  gauze  fixed  in  position  by  flexile 
collodion.  The  best  way  of  introducing  a  buried  suture  is  to  take  a 
curved  Hagedorn  needle  threaded  with  the  finest  catgut,  and  pass  it 
through  the  fat  and  deeper  part  of  the  dermis  on  one  side  of  the  wound, 
and  then  through  the  fat  and  deeper  part  of  the  dermis  on  the  other, 


FIG.  45. — A  BURIED  SUTURE.  The  figure  shows  how,  by  making  the  free  end  of  the 
suture  emerge  on  each  side  through  the  deeper  part  of  the  dermis  and  the  adjacent 
subcutaneous  tissues,  the  knot  can  be  easily  pushed  out  of  the  way  among  the  fat  when  it 
is  tied.  If  it  were  done  in  the  reverse  way  the  knot  would  lie  between  the  lips  of  the 
incision,  and  would  interfere  with  perfect  coaptation.  The  ends  of  the  suture  are  cut  off 
quite  short  and  pushed  down  out  of  the  way  by  means  of  a  probe. 

the  needle  being  made  to  enter  the  fat  and  emerge  through  the  dermis 
on  the  one  side,  and  vice  versa  on  the  other.  Several  stitches  are  passed, 
and  they  are  then  tied  and  the  ends  cut  short,  the  knot  being  pushed 
down  into  the  fatty  tissues  beneath  the  dermis  (see  Fig.  45).  These 
sutures  hold  the  deeper  parts  of  the  skin  firmly  together.  A  strip  <)f 
gauze  is  then  fixed  upon  one  side  of  the  wound  with  collodion,  and  when 
it  is  dry  the  skin  on  the  other  side  is  pressed  inwards  towards  the  line  of 
incision,  and  the  free  end  of  the  gauze  strip  is  fastened  down  upon  it 
with  collodion.  As  far  as  the  gauze  and  collodion  are  concerned,  the  pro- 
cedure closely  resembles  the  old-fashioned  method  of  applying  strapping  to 
draw  the  edges  of  wounds  together,  and  is  similar  to  the  plan  adopted 
in  hare-lip  operations.  By  its  means  the  epithelial  edges  are  approximated, 
and  stitch  marks  are  absolutely  avoided,  so  that  only  a  very  delicate  linear 
scar  is  left,  which  in  a  short  time  becomes  quite  unnoticeable.  Where 
there  is  no  special  reason  for  avoiding  stitch  marks,  the  best  plan  is  to 
close  the  wound  by  a  continuous  button-hole  stitch  of  fine  silk  (see  p.  158). 
(b)  Where  there  is  great  tension. — In  many  cases,  after  operation 
for  the  removal  of  tumours,  etc.,  as,  for  example,  after  excision  of  the 
breast,  there  is  a  considerable  deficiency  of  skin,  and  the  result  is  that  the 
edges  of  the  wound  will  not  come  together  without  considerable  traction. 


TREATMENT   OF    INCISED   WOUNDS.  155 

If  the  skin  be  pinched  up  by  a  stitch  that  is  too  tight,  persistent  irritation 
is  caused,  and  perfect  union  may  fail ;  at  any  rate  it  will  not  be  so  rapid 
and  firm  as  it  should  be.  It  is  therefore  very  important,  when  inserting 
sutures,  to  see  that  no  stitch  is  tighter  than  is  absolutely  necessary  to 
approximate  the  edges  of  the  skin.  Where  there  is  much  difficulty  in 
bringing  the  edges  together,  however,  a  certain  amount  of  irritation  must 
necessarily  be  caused  by  the  stitches,  but  this  can  be  to  a  great  extent 
reduced  by  introducing  a  few  so-called  "  stitches  of  relaxation "  (Lister), 
at  some  considerable  distance  from  the  edges  of  the  wound.  The  tension 
upon  these  may  be  great,  and  they  may  subsequently  to  a  certain  extent 
cut  through  the  soft  parts;  but,  temporarily  at  any  rate,  they  serve  to  relax 
the  edges  of  the  wound,  which  may  then  be  stitched  together  without 
any  tension,  with  the  result  that  they  will  heal  by  primary  union.  Hence, 
two  classes  of  sutures  are  used  in  cases  where  the  edges  of  the  wound 
require  to  be  pulled  together,  namely,  a  set  of  stitches  of  relaxation,  and 
others  which  may  be  termed  "  stitches  of  coaptation." 

"Stitches  of  Relaxation." — Stitches  of  relaxation  are  employed,  then, 
for  the  purpose  of  taking  off  the  strain  from  those  of  coaptation,  and  they 
require  to  be  inserted  at  a  considerable  distance  from  the  edges  of  the 


FIG.  46. — LISTER'S  NEEDLE.     The  groove  for  the  reception  of  the  wire  is  seen  beyond 
the  eye  of  the  needle. 

wound,  and  must  be  reasonably  stout,  because  a  thin  stitch  would  cut  its 
way  out  too  quickly;  the  best  material  for  this  purpose  is  thick  silver 
wire  (the  most  suitable  size  being  that  commonly  sold  as  No.  i  or  No. 
2).  Special  needles,  "Lister's  pattern"  (see  Fig.  46),  must  be  employed 
for  introducing  them.  In  these  needles  the  wire  is  threaded  through  an  eye 
at  some  distance  from  the  end,  while  between  the  eye  and  the  end  of  the 
needle  there  is  a  groove,  into  which  the  wire  is  pressed,  so  that  where 
the  needle  goes  the  wire  follows  without  any  unnecessary  tearing  of  the 
structures  through  which  it  passes.  In  threading  these  needles,  two  or 
three  inches  of  the  wire  are  passed  through  the  eye  and  flattened  into  the 
groove ;  the  end  of  the  needle  is  then  held  with  forceps,  and  the  two 
ends  of  the  wire  are  carefully  twisted  together  (see  Fig.  47).  If  one  end 
of  the  wire  be  merely  twisted  round  the  other,  a  number  of  irregularities 
are  left,  which  catch  in  the  wound  when  the  stitch  is  pulled  through. 
Another  point  with  regard  to  the  use  of  silver  wire  for  this  purpose  may 
be  mentioned.  Pure  drawn  silver  wire  without  any  alloy  must  be  employed, 
and  if  it  kink  it  must  not  be  straightened  by  passing  it  between  the  finger 
and  thumb,  as  is  so  often  done.  This  destroys  the  suppleness  of  the 
wire  at  once,  and  it  cannot  be  tied  into  a  knot ;  each  end  should  be 
grasped  in  a  pair  of  forceps,  and  the  wire  straightened  by  pulling  upon 


156  WOUNDS. 

them.  The  portions  grasped  by  the  forceps  are  then  cut  off,  and  the 
wire  is  ready  for  use.  If  the  suppleness  has  been  lost,  it  can  be  immedi- 
ately restored  by  passing  the  wire  through  the  flame  of  a  spirit  lamp. 


FIG.  47. — METHOD  OP  THREADING  LISTER'S  NEEDLE  WITH  WIRE.  The  needle  is 
shown  grasped  at  the  extreme  end  by  a  pair  of  dressing  forceps.  The  forceps  held  in  one 
hand  serve  to  fix  the  needle  and  to  flatten  the  wire  into  its  groove  while  the  wire  is  care- 
fully twisted  np  with  the  fingers  of  the  other  hand.  The  twists  should  always  be  close 
and  regular,  as  in  the  figure,  or  they  will  be  liable  to  catch  in  the  skin. 

In  order  to  fix  wire  stitches  ot  this  kind,  if  the  tension  be  not  very 
great,   the  first  half  of  a  reef  knot  should  be  tied,  the  ends  turned  up  at 


FIG.  48. — METHOD  OF  SUTURING  A  WOUND  WHERE  THERE  is  MUCH  TENSION  ox 
THE  EDGES.  On  either  side  is  a  pair  of  button  sutures,  showing  the  figure-of-eight 
arrangement  by  which  the  wire  is  fastened.  In  the  centre  is  a  relaxation  stitch  of  stout 
silver  wire  showing  the  manner  in  which  the  wire  is  tied  and  its  ends  clipped  off.  A  con- 
tinuous "  button-hole  "  stitch  unites  the  edges  of  the  skin  which,  by  the  aid  of  the  button 
sutures  and  the  silver  wire  stitch,  come  together  without  tension.  The  puckering  of  the 
skin  caused  by  the  tension  upon  the  button  sutures  and  silver  wire  stitch  is  also  indicated. 
The  skin  has  been  freely  undermined. 

right  angles,    and   then   clipped   off   flush    with    the    surface    of    the   wire 
(see  Fig.   48) ;    if  the  wire   be   stout,   this   will   hold   perfectly  well,    while 


TREATMENT   OF   INCISED   WOUNDS.  157 

there  is  no  projecting  end  left  to  catch  in  the  dressing.  Where  the 
tension  is  great,  a  second  twist  must  be  made,  and  the  ends  cut  off  and 
bent  down  on  to  the  skin.  All  chance  of  the  wire  catching  in  the 
dressing  may  be  avoided  by  interposing  a  layer  of  oiled  silk  protective 
between  the  latter  and  the  wound.  A  sufficient  number  of  these  deep 
silver  wire  stitches  must  be  put  in  to  enable  the  edges  of  the  wound  to 
be  brought  together  without  any  tension. 

Undermining  Flaps. — Where  much  skin  has  been  taken  away,  the  edges 
cannot  usually  be  brought  together  properly  with  stitches  unless  the  skin 
be  widely  freed  by  undermining  it.  By  this  means  the  skin  and  fat  are 
separated  from  the  deeper  parts  for  a  considerable  distance,  sometimes 
for  a  good  many  inches,  and  the  elasticity  of  the  skin  allows  the  flap 
of  skin  thus  formed  to  stretch,  and  the  cut  edges  to  meet  (see  also  p.  178). 

Button  Sutures. — Where  the  tension  is  very  great,  the  "button  sutures" 
introduced  by  Lord  Lister  may  be  employed  with  advantage.  A  needle 
threaded  with  stout  silver  wire  (see  above)  is  inserted  through  the  skin 
several  inches  from  the  edge  of  the  undermined  flap,  at  the  outer  limit  of 
the  undermining,  and  the  free  end  of  this  is  attached  to  a  lead  button 
(see  Fig.  48).  The  wire  is  then  carried  across  the  wound,  and  the  needle 
brought  out  through  the  skin  at  the  corresponding  spot  on  the  opposite 
side  where  the  undermining  ceases.  The  needle  is  then  cut  off,  and  over 
the  cut  end  of  the  wire  is  threaded  a  second  button,  which  is  pushed  as 
far  down  as  possible,  while  firm  traction  is  made  on  the  wire,  and  the 
latter  secured  in  place.  Only  a  few  of  these  button  stitches  need  be  put 
in ;  as  a  rule,  in  a  breast  case,  two  pairs  are  sufficient.  The  larger  the 
button  used  the  better;  the  pressure  is  then  more  evenly  distributed  over 
the  skin,  and  there  is  less  likelihood  of  sloughing.  If  a  small  button  be 
employed,  the  skin  may  very  possibly  slough  where  the  button  presses 
upon  it ;  in  any  case,  a  small  slough  generally  forms  where  the  wire  pene- 
trates the  skin,  but  this  causes  no  trouble  if  the  wound  be  aseptic,  and  it 
heals  readily  when  the  buttons  are  removed.  Several  stitches  of  relaxation 
will  also  be  required  to  support  and  take  off  tension  from  the  edges  of 
the  wound.  These  will  be  inserted  about  midway  between  the  buttons 
and  the  edge  of  the  wound  (see  above). 

The  button  stitches  are  usually  left  in  for  about  five  or  six  days,  and 
they  are  the  first  sutures  to  be  removed,  partly  because  the  skin  will  not 
retract  after  being  stretched  for  that  length  of  time,  and  partly  because  if 
they  are  left  in  longer  they  are  apt  to  cause  a  slough. 

(c]  Where  there  is  moderate  tension. — Where  the  traction  required  to 
bring  the  edges  together  is  only  moderate,  a  very  good  material  for  a 
stitch,  and  one  that  is  intermediate  between  one  of  relaxation  and  one  of 
coaptation,  is  silkworm  or  fishing  gut.  This  is  fairly  thick,  and,  if  a  good 
hold  of  the  skin  be  taken,  the  latter  can  be  made  to  bear  a  considerable 
amount  of  tension  without  bad  results. 

"  Stitches   of  Coaptation." — For    the    stitches    of  coaptation,    that   is   to 


158 


WOUNDS. 


say,  the  stitches  employed  to  bring  the  edges  of  the  wound  accurately 
together,  it  was  formerly  the  practice  to  use  interrupted  sutures,  each 
suture  being  separately  inserted,  knotted  and  divided.  Of  late,  we  have 
employed  a  continuous  suture,  which  has  the  advantage  that  the  edges 
are  more  accurately  approximated  and  that  the  suture  is  much  more  rapidly 
inserted,  a  point  that  is  of  great  importance  when,  at  the  end  of  a  long  or 
severe  operation,  a  large  wound  requires  to  be  closed. 


FIG.  49. — BUTTON-HOLE  OR  BLANKET  STITCH.  The  figure  shows  the  thread  looped 
behind  the  needle  as  it  emerges  from  the  skin.  The  first  loop  of  the  suture— at  the  left- 
hand  end  of  the  figure — is  knotted  in  the  ordinary  way ;  the  remaining  loops  are  made  as 
shown  at  the  right-hand  end. 

The    best  form   of  continuous  suture  is  that  resembling  the  blanket  or 
button-hole  stitch  (see   Fig.  49).     In  the   first  place   an  ordinary  suture   is 


FIG.  50. — METHODS  OF  FINISHING  OFF  THE  BUTTON-HOLE  SUTURE.  A.  As  the  needle 
emerges  through  the  skin  for  the  last  time,  the  thread  is  twisted  around  it  three  or  four 
times.  The  needle  is  then  pulled  through  and  the  stitch  pulled  tight.  A  perfectly 
satisfactory  knot  can  be  thus  made  with  a  little  practice.  B.  Shows  a  method  very  com- 
monly used.  When  the  needle  is  passed  through  the  skin  for  the  last  time  it  is  not 
brought  out  inside  the  loop  from  the  last  stitch  ;  the  free  end  shown  on  the  left-hand  side 
of  the  incision  is  taken  in  one  hand,  the  loop  shown  on  the  right-hand  side  in  the  other, 
and  the  two  are  then  tied  together.  This  is  a  simple  method,  but  causes  a  little 
puckering.  C.  Shows  the  method  employed  by  Professor  Rose  to  obviate  this  puckering. 
In  passing  the  needle  through  the  skin  for  the  last  time  it  is  made  to  go  in  the  opposite 
direction,  i.e.  in  the  diagram  from  left  to  right,  whereas  the  rest  of  the  stitch  is  made  from 
right  to  left.  The  free  end  shown  on  the  left-hand  side  of  the  incision  is  then  held  in 
one  hand  while  traction  is  made  upon  the  needle  with  the  other ;  the  result  is  that  the 
last  loop  is  drawn  tight  and  the  wound  is  closed.  The  free  end  on  the  one  side  and  the 
loop — or  the  two  free  ends  if  the  needle  be  cut  off — on  the  other  are  then  tied  together. 
This  is  a  very  simple  and  effective  plan. 

inserted  and  tied,  to  prevent  the  suture  slipping;  then,  instead  of  cutting 
the  suture,  the  needle  is  passed  through  the  two  edges  of  the  wound,  and 
brought  out  inside  the  loop  formed  by  the  thread,  and  drawn  tight,  and 


TREATMENT   OF   INCISED   WOUNDS.  159 

this  is  continued  till  the  whole  wound  is  stitched  up ;  the  end  may  be 
secured  either  by  leaving  the  last  loop  long  and  tying  a  knot  between 
it  and  the  free  end  of  the  thread,  or  by  taking  several  turns  of  the  thread 
around  the  needle  as  it  forms  the  last  loop  and  then  tightening  it  up 
(see  Fig.  50).  The  result  is  that  along  one  side  of  the  wound  there  is 
a  continuous  thread  of  silk,  which  acts  very  like  the  old  quilled  suture. 
This  stitch  is  better  than  the  herring-gut  stitch,  which  was  at  one  time 
frequently  employed  in  uniting  intestine,  and  which  tends,  if  drawn  at  all 
tight,  to  pucker  up  the  edges,  and  may  even  cause  gangrene  of  portions 
of  them.  If  the  dressings  have  been  allowed  to  dry,  the  threads  will, 
after  a  few  days,  be  found  stuck  together  with  blood,  and  if  any  one  of 
the  stitches  be  too  tight,  it  can  be  divided  or  removed  without  the  rest 
of  the  stitch  necessarily  giving  way.  The  best  material  for  the  continuous 
suture  is  silk,  of  the  variety  known  as  Chinese  twist,  varying  in  thickness 
according  to  the  amount  of  tension  to  which  it  is  exposed.  Where  there 
is  no  tension,  quite  a  fine  silk  is  sufficient;  but  where  there  is  much,  it  is 
better  to  use  silk  of  medium  thickness,  as  the  fine  thread  cuts  out  very 
quickly  under  these  circumstances. 

Summary  of  methods  of  Suturing  Wounds. — What  has  been  said  with 
regard  to  stitches  may  be  summed  up  as  follows.  Where  there  is  no 
tension  on  the  edges  of  the  wound,  and  a  very  small  fine  scar  is  required, 
either  buried  sutures  may  be  used,  with  no  sutures  in  the  skin  at  all,  or 
the  finest  horse-hair  may  be  employed.  Where  very  great  tension  is  present, 
button  sutures  should  be  used,  after  undermining  the  flaps,  and  in  addition 
to  them,  deep  relaxation  stitches  of  silver  wire  should  also  be  inserted, 
these  being  sufficiently  numerous  to  support  the  edges  of  the  flap,  which 
should  be  coapted  by  a  fine  continuous  button-hole  stitch.  Where  there 
is  only  a  moderate  amount  of  tension,  interrupted  silkworm  gut  stitches, 
reinforced  by  a  fine  continuous  coaptation  suture  of  silk,  may  be  made 
use  of;  and  lastly,  where  there  is  little  or  no  tension  and  where  stitch 
marks  are  unimportant,  the  edges  may  be  approximated  by  means  of  thick 
or  fine  silk. 

Removal  of  Sutures. — It  has  already  been  said  (see  p.  157)  that  button 
sutures  should  be  removed  in  about  five  or  six  days.  Where  there  are 
also  silver  relaxation  stitches,  and  the  wound  is  dressed  for  the  purpose 
of  removing  the  buttons,  the  continuous  silk  suture  can  as  a  rule  be  taken 
out  at  the  same  time,  only  the  deep  silver  stitches  being  left.  The  removal 
of  these  latter  must  depend  on  the  firmness  of  union  between  the  edges, 
but  generally  they  can  all  be  taken  out  at  the  end  of  a  week  or  ten  days. 
If  there  be  any  point  where  the  strength  of  the  union  is  doubtful,  as 
for  instance  where  a  triangular  flap  of  skin  has  been  dragged  up  to  meet 
two  other  flaps,  the  stitches  at  the  apex  of  the  flap  should  generally  be 
left  for  about  a  fortnight.  With  the  exception  of  cases  where  button 
sutures  have  been  used,  there  is  no  necessity  to  dress  the  wound  for 
the  purpose  of  removing  any  stitch  before  firm  union  has  occurred,  and 


l6o  WOUNDS 

we  seldom  dress  a  wound  until  about  ten  days  after  the  operation,  unless 
these  sutures  have  been  employed. 

Avoidance  Of  Movement. — The  importance  of  avoiding  movement 
of  any  part  in  which  healing  by  first  intention  is  aimed  at,  has  already 
been  referred  to  (see  p.  150),  and  this  should  be  provided  for  in  all  wounds. 
In  operations  on  the  extremities,  a  suitable  splint  must  be  applied  to 
control  the  movements  of  the  neighbouring  joints,  and  this  should  be 
kept  on  for  about  a  week  or  ten  days.  In  operations  upon  the  abdomen 
a  firm  binder  will  usually  ensure  rest,  if  the  patient  be  forbidden  to  sit 
up.  In  breast  operations  the  arm  should  be  so  fixed  that  the  pectoral 
muscles  are  kept  at  rest.  In  operations  about  the  neck,  it  is  usual  to 
put  on  an  extra  amount  of  dressing,  which  is  firmly  fixed  with  a  bandage, 
so  that,  when  the  deeper  part  becomes  stiffened  by  the  dried  blood,  and 
is  supported  by  the  large  mass  of  dressing  outside  it,  it  practically  forms 
a  splint  for  the  head  and  neck :  some  surgeons  employ  a  specially  moulded 
collar  of  poroplastic  material  or  guttapercha,  but  this  is  rarely  necessary. 

Avoidance  of  Irritation. — Care  must  also  be  taken  to  prevent 
irritation  of  the  wound  by  antiseptic  solutions  or  dressings ;  but  if  a 
wound  be  not  dressed  till  it  has  healed,  as  is  our  usual  rule,  there 
will  of  course  be  no  irritation  resulting  from  antiseptic  lotions.  The 
chief  point  of  importance,  therefore,  centres  in  the  choice  of  the  dressings, 
which  must  not  exert  any  chemical  or  mechanical  irritation.  With  regard 
to  the  former  point,  care  is  taken  that  the  gauze  placed  next  the  wound 
shall  not  contain  any  soluble  irritating  antiseptic  substance;  this  will 
again  be  dealt  with  immediately.  The  mere  presence  of  the  gauze  over 
a  wound,  the  edges  of  which  have  been  properly  brought  together,  does 
not  at  all  interfere  with  healing  by  first  intention,  particularly  if  the  wound 
be  left  undisturbed  for  a  week  or  ten  days.  Where  silver  stitches  are 
used,  the  ends  of  the  wire  are  very  prone  to  become  entangled  in  the 
gauze,  and  any  movements  of  the  patient  may  drag  upon  them ;  this  can 
be  avoided  by  interposing,  between  the  line  of  incision  and  the  gauze 
dressing,  a  narrow  strip  of  Lister's  protective  oiled  silk,  previously  sterilised 
by  immersion  in  1-20  carbolic  lotion  and  then  washed  in  1-2000  sublimate 
solution  immediately  before  being  applied.  Where  button  stitches  are 
used,  each  button  should  also  be  covered  with  a  piece  of  this  material, 
but  care  must  be  taken  that  the  dressing  overlaps  the  latter  for  a  considerable 
distance  in  all  directions;  if  not,  sepsis  may  very  readily  spread  in 
beneath  it. 

Exclusion  of  Micro-Organisms. — The  next  point  in  the  treatment 
of  wounds,  namely,  the  exclusion  of  micro-organisms,  is  most  important ; 
indeed,  it  is  the  really  essential  one.  Even  if  the  steps  necessary  for  the 
exclusion  of  micro-organisms  were  to  interfere  with  healing  by  first  intention, 
it  would  still  be  incumbent  on  the  surgeon  to  see  that  they  were  carried 
out,  on  account  of  the  disastrous  results  that  follow  the  entrance  of  micro- 
organisms into  a  wound.  As  a  matter  of  fact,  however,  they  can  be 


TREATMENT   OF   INCISED   WOUNDS.  161 

excluded  without  in  any  way  interfering  with  healing  by  first  intention. 
The  exclusion  of  organisms  during  and  after  the  performance  of  an  operation 
is  the  essential  Listerian  principle,  and  at  the  present  time  two  plans  are 
adopted  for  carrying  it  out.  One  is  that  which  was  originally  introduced  by 
Lister  and  has  since  undergone  many  modifications;  it  consists  in  the  pre- 
liminary disinfection  of  skin,  hands,  instruments,  etc. ;  in  the  use  of  antiseptic 
substances  during  the  course  of  the  operation ;  and  in  the  subsequent 
application  to  the  wound  of  dressings  containing  antiseptics.  In  the  other 
method  (sometimes  termed  the  "aseptic"  method),  while  in  the  preliminary 
stages  the  procedures  are  essentially  the  same,  the  use  of  antiseptic  sub- 
stances during  the  course  of  the  operation  and  afterwards  in  the  dressings 
is  avoided  (see  p.  173).  There  is  no  real  antagonism  between  the  two 
plans;  it  is  merely  a  difference  in  the  mode  by  which  the  same  end  is 
attained.  In  our  opinion,  the  exclusion  of  micro-organisms  is  attained  in 
practice  much  more  certainly  by  the  use  of  antiseptics  than  by  the  other 
plan. 

Sources  of  Infection  by  Micro-Organisms. — Micro-organisms  may 
enter  a  wound  firstly  from  the  skin  in  the  neighbourhood  of  the  wound 
itself;  secondly,  from  the  hands  of  the  operator  or  his  assistants ;  thirdly, 
from  the  instruments,  ligatures,  etc.,  that  are  used  during  the  course  of 
the  operation ;  and  fourthly,  from  the  air.  The  first  three  of  these  sources 
must  receive  special  attention,  and,  if  they  be  properly  guarded  against,  it 
will  practically  always  be  possible  to  obtain  an  aseptic  wound.  The 
organisms  which  fall  in  from  the  air  are  usually  non-pathogenic,  and  will 
not  grow  in  a  wound  the  walls  of  which  are  brought  properly  into  contact 
during  healing. 

Disinfection  of  the  Skin. — Micro-organisms  are  always  present  in 
the  skin  and  are  most  numerous  where  it  is  moist,  as,  for  example,  in  the 
axillae,  in  the  perineum,  between  the  toes,  and  in  the  various  folds  of  the 
skin.  They  are  found  not  only  in  the  old  epithelium  upon  the  surface, 
but  also  about  the  hairs,  and  they  seem  to  penetrate  to  a  certain  distance 
into  the  hair  follicles  and  sebaceous  glands ;  hence  their  complete  eradication 
is  a  matter  of  some  little  difficulty.  In  order  to  get  rid  of  them,  anti- 
septic substances  must  be  used,  whichever  of  the  two  methods  referred  to 
above  is  to  be  employed.  In  the  first  place,  the  skin  for  a  considerable 
distance  around  the  area  of  the  proposed  operation  wound  should  be  shaved, 
and  the  grease  which  is  present  on  the  surface  of  the  skin,  and  which 
prevents  the  action  of  most  antiseptic  solutions,  must  be  removed.  This 
may  be  effected  by  means  of  turpentine,  benzine,  ether,  alcohol,  etc.  We 
prefer  turpentine,  which  is  a  very  efficient  solvent  of  fat,  while  at  the  same 
time  it  possesses  a  certain,  though  slight,  antiseptic  action.  After  the  skin 
has  been  shaved  it  should  be  well  rubbed  with  turpentine,  and  this  should 
be  done  with  special  thoroughness  when  the  operation  is  in  the  neigh- 
bourhood of  parts  that  are  normally  hairy,  as,  for  example,  the  axillae  or 
the  pubes.  After  this  the  part  is  thoroughly  washed  and  scrubbed  with 


162  WOUNDS. 

soap  and  1-20  carbolic  acid  solution,  or  still  better,  a  1-20  watery 
solution  of  carbolic  acid  containing  7^th  part  of  corrosive  sublimate  (this 
we  have  already  referred  to  as  the  "strong  mixture").  This  cleansing 
should  be  done  with  great  thoroughness,  and  several  minutes  should  be 
devoted  to  it;  in  the  first  place  the  washing  should  be  done  with  the 
hands,  and  afterwards  the  skin  should  be  scrubbed  with  a  nail-brush  which 
has  been  soaked  for  some  time  in  the  strong  mixture.  Indeed,  wherever 
it  can  be  managed,  the  purification  of  the  skin  should  take  place  some 
hours  before  the  operation,  and  a  piece  of  gauze  soaking  in  1-20  carbolic 
acid  solution  should  be  fixed  over  the  part  so  as  to  prolong  the  disinfection ; 
in  any  case,  however,  the  process  should  be  repeated  immediately  before 
the  operation.  Before  the  incision  is  made  the  strong  mixture  remaining 
on  the  surface  of  the  skin  should  be  washed  away  with  a  1-2000  sublimate 
solution.  It  is  always  necessary  to  purify  a  wide  area  of  the  skin  all 
around  the  neighbourhood  of  the  operation  wound. 

Precautions. — In  children  or  those  suffering  from  pyrexia  (for  example, 
hectic  fever),  it  is  advisable  not  to  wrap  the  part  up  in  a  carbolic  dressing 
after  disinfection,  as  the  drug  is  very  apt  to  be  absorbed  and  may  lead 
to  dangerous  symptoms  of  poisoning.  The  carbolic  acid  must  no  doubt  be 
used  for  the  disinfection  of  the  skin  immediately  before  the  operation, 
but  then  only  very  little  if  any  absorption  will  occur;  in  these  cases  the 
wet  gauze  or  cloth  which  is  afterwards  put  on  to  continue  the  disinfection 
should  be  simply  soaked  in  a  1-2000  sublimate  solution. 

Disinfection  of  the  Hands. — The  disinfection  of  the  hands  of  the 
operator  and  his  assistants  is  also  a  point  which  must  be  scrupulously 
attended  to.  Special  attention  must  be  directed  to  the  thorough  cleansing 
of  the  nails,  by  the  removal  of  the  dirt  beneath  them,  and  of  the  old 
dead  epithelium  in  the  folds  about  them.  The  disinfection  should  not  be 
limited  to  the  fingers,  but  should  involve  the  whole  hand,  wrist  and 
forearm,  as  far  as  the  elbow.  It  must  be  carried  out  in  precisely  the 
same  manner  as  that  employed  for  disinfecting  the  patient's  skin :  first  by 
washing  the  hands  thoroughly  with  hot  water  and  soap,  then  soaking 
them  with  turpentine,  and  finally  using  a  nail-brush  with  soap  and  strong 
mixture.  The  nails  should  be  cut  short,  and  all  dirt  and  epithelial  debris 
beneath  and  around  them  removed  by  a  suitable  nail-cleaner.  The  process 
of  disinfection  should  last  at  least  ten  minutes,  and  after  it  is  complete, 
the  hands  should  not  be  dried  upon  a  towel,  but  should  be  rinsed  in  a 
1-2000  sublimate  solution,  and  a  basin  of  this  should  be  at  hand  so  that 
the  hands  may  be  frequently  dipped  in  it  during  the  course  of  the  opera- 
tion. It  is  very  often  the  custom  after  disinfecting  the  hands  to  wipe  them 
on  a  dry  towel,  but  unless  the  latter  be  perfectly  aseptic,  this  is  simply 
to  cover  them  again  with  dust.  We  strongly  recommend  that  the  hands 
should  never  be  allowed  to  dry  after  disinfection,  but  should  always  be  kept 
wet  with  a  1-2000  sublimate  solution,  the  blood  being  frequently  washed 
off  the  hands  by  means  of  this  solution  during  the  course  of  the  operation. 


TREATMENT   OF   INCISED   WOUNDS.  163 

Disinfection  of  Instruments. — The  purification  of  instruments  is 
carried  out  as  follows.  After  an  operation  they  are  thoroughly  washed  and 
cleaned  by  means  of  a  nail-brush,  immersed  in  a  1-20  carbolic  acid 
solution,  dried  and  put  into  a  press  with  glass  shelves  where  they  can  be 
kept  free  from  dust.  If  they  have  been  used  for  a  septic  case,  they  should 
be  boiled  before  being  put  away,  otherwise  the  instrument  case  itself  may 
become  contaminated.  If  this  be  done,  there  is  not  much  disinfection 
required  immediately  before  use,  and  it  will  suffice  in  the  majority  of  cases 
to  immerse  the  instruments  in  a  1-20  carbolic  acid  solution  for  half  an  hour 
or  longer  before  the  commencement  of  the  operation.  Where  there  is  not 
sufficient  time  for  prolonged  immersion  of  the  instruments  in  the  carbolic 
acid  solution,  or  if  the  nature  of  the  case  demands  extra  precautions,  they 
may  be  disinfected  by  dipping  them  for  a  few  minutes  in  undiluted  carbolic 
acid,  and  subsequently  immersing  them  in  a  1-20  carbolic  solution.  This 
can  readily  be  done  by  pouring  out  a  sufficient  quantity  of  the  pure  acid 
into  a  jar  or  dish,  dipping  the  instruments  into  it,  and  then  transferring 
them  to  the  1-20  solution.  This  latter  method  is  also  the  best  where  an 
instrument  is  required  in  a  hurry  during  the  progress  of  an  operation,  and 
where  there  is  no  time  to  boil  it  or  to  immerse  it  in  the  lotion  for  a 
sufficient  length  of  time. 

Boiling  instruments  is  doubtless  a  very  certain  method  of  disinfecting 
them,  and  is  to  be  strongly  recommended  where  it  can  be  carried  out, 
and  where  the  instruments  are  entirely  metal.  It  is  very  readily  done  by 
placing  them  in  a  sheet  or  bag  of  gauze,  and  immersing  them  in  a  vessel 
of  boiling  water  to  which  a  little  soda  has  been  added.  Special  '  sterilisers ' 
are  sold  for  the  purpose;  they  are  provided  with  a  perforated  tray  which, 
like  the  sheet  of  gauze,  enables  the  instruments  to  be  removed  easily 
when  they  have  been  boiled  for  a  sufficient  length  of  time.  They  should 
be  kept  at  the  boiling  point  for  at  least  ten  minutes,  and  should  then  be 
transferred  to  the  1-20  carbolic  solution.  Prolonged  boiling  of  this  kind  is 
apt  to  destroy  the  cutting  edge  of  steel  instruments,  and  for  them  pure 
carbolic  acid  or  a  prolonged  immersion  in  the  1-20  solution  is  preferable. 
It  is  also  well,  when  steel  instruments  are  to  be  disinfected  by  boiling, 
not  to  immerse  them  until  the  water  is  actually  boiling;  this  avoids  dis- 
coloration. 

Preparation  of  Ligatures. — The  disinfection  of  the  catgut,  silk, 
silver  wire,  or  other  materials  used  for  ligatures  or  stitches,  may  be  effected 
by  immersion  in  carbolic  acid.  It  may  be  taken  as  certain  that  immersion 
in  a  1-20  watery  carbolic  solution  for  from  24  to  48  hours  will  destroy 
any  organisms  to  which  the  fluid  has  free  access.  Our  rule  is  therefore  to 
keep  these  materials  constantly  in  this  solution,  which  is  renewed  every 
three  or  four  days  on  account  of  the  loss  of  carbolic  acid,  and  we  do  not 
use  any  material  that  has  not  been  soaking  for  at  least  a  week.  As  soon 
as  the  supply  is  seen  to  be  running  short  a  fresh  quantity  is  put  in,  so  as 
to  always  have  enough  ready  for  use.  Some  surgeons  boil  their  silk  before 


164  WOUNDS. 

the  operation,  but,  while  there  is  no  objection  to  this  procedure,  it  is 
unnecessary.  As  it  is  impossible  to  treat  catgut  in  this  manner  (it  would 
be  spoilt  by  boiling),  the  method  would  involve  treating  the  silk  in  one 
way  and  the  catgut  in  another.  If  silk  be  boiled,  it  should  afterwards  be 
placed  in  a  1-2000  sublimate  solution  until  it  is  required  for  use. 

Preparation  of  Sponges. — The  proper  preparation  of  the  sponges 
is  of  great  importance.  The  most  satisfactory  method  of  removing  blood 
from  a  wound  is  by  the  ordinary  marine  sponge;  in  our  opinion,  a  much 
more  satisfactory  plan  in  many  ways  than  the  use  of  swabs  of  absorbent 
cotton  wool,  which  have  come  very  much  into  fashion  of  late  years.  In 
the  first  place,  sponges  soak  up  blood  better;  in  the  second  place,  when 
using  swabs,  shreds  of  cotton  wool  are  apt  to  be  left  behind  in  the  wound ; 
and  in  the  third  place,  the  swabs  as  ordinarily  prepared  by  nurses  are  very 
often  septic. 

After  an  operation  the  sponges  are  thoroughly  washed,  first  with  cold 
water  to  remove  as  much  of  the  fibrin  as  possible,  and  then  with  soda 
and  warm  water;  and  it  is  well  to  leave  them  soaking  in  water  for 
from  24  to  48  hours,  rinsing  them  well  once  or  twice  during  that  time  in 
order  to  free  them  more  rapidly  from  the  fibrin  or  mucus  that  has  become 
entangled  in  them.  At  the  end  of  the  time  they  are  again  thoroughly 
washed  and  squeezed  dry,  and  are  then  placed  in  a  vessel  containing  a 
1-20  carbolic  solution.  They  should  be  kept  in  this  for  at  least  a  week 
before  they  are  again  used,  the  carbolic  being  changed  every  second  or 
third  day  on  account  of  its  loss  of  strength  from  the  evaporation  of  the 
acid.  If  this  be  done,  there  is  no  objection  whatever  to  the  use  of  sponges, 
and  they  are  much  more  convenient  than  swabs.  The  mode  of  cleansing 
them  during  an  operation  will  be  referred  to  immediately  (see  p.  166). 

Swabs. — The  only  case  where  the  use  of  swabs  is  advisable  is  where 
there  is  a  foul  septic  wound,  as  in  extravasation  of  urine,  or  in  operations 
about  the  rectum,  as,  for  example,  in  piles  or  fissure  of  the  anus.  If  swabs 
be  employed,  they  should  be  made  of  salicylic  or  plain  absorbent  wool, 
and  wrapped  up  in  gauze  to  prevent  as  far  as  possible  threads  of  the 
wool  being  left  in  the  wound,  and  when  they  are  thus  made  they  should 
be  boiled.  Before  use  it  is  well  to  squeeze  them  out  of  a  1-2000  sublimate 
solution,  and  indeed,  if  they  are  used  for  antiseptic  work,  they  should  be 
handed  to  the  surgeon  or  his  assistant  in  a  bowl  of  this  solution,  out  of 
which  he  should  squeeze  them  himself.  The  nurse  should  never  be  trusted 
to  do  this,  as  she  is  very  apt  to  soil  them  afterwards  ;  the  same  remark 
applies  to  sponges  (see  p.  166). 

Precautions  during  course  of  Operation. — Having  in  this  way 
rendered  aseptic  everything  coming  in  contact  with  the  wound,  further 
precautions  must  be  taken  during  the  course  of  the  operation  to  see  that 
no  infection  of  the  instruments,  sponges,  etc.,  shall  by  any  chance  occur; 
and  the  most  essential  of  these  precautions  is  to  surround  the  area  of  the 
operation  with  towels  rendered  aseptic  by  being  wrung  out  of  hot  antiseptic 


TREATMENT   OF    INCISED    WOUNDS.  165 

solutions.  If  these  wet  antiseptic  towels  are  placed  all  around  the  area 
of  operation,  instruments  laid  down  upon  them  do  not  become  contaminated, 
and  the  same  is  the  case  if  the  hands  of  the  operator  or  his  assistants  rest 
upon  them.  It  is  well  to  see  that  the  preparation  of  these  towels  is 
thoroughly  carried  out,  and  what  is  'usually  done  at  our  hospitals  is  that 
the  towels  are  boiled  and  then  put  to  soak  in  hot  1-20  carbolic  acid 
solution  two  or  three  hours  before  the  time  fixed  for  the  operation ;  they 
are  taken  out  of  this  immediately  before  use,  immersed  in  a  1-2000  sub- 
limate solution,  and  then  lightly  wrung  out  and  applied  directly  to  the 
field  of  operation.  In  private  practice,  except  in  operations  of  emergency, 
it  is  quite  easy  to  instruct  a  nurse  to  have  this  done.  When  towels  are 
prepared  in  this  way,  their  asepticity  may  be  thoroughly  relied  upon. 
When  an  operation  has  to  be  done  in  a  hurry,  it  will  suffice  to  thoroughly 
soak  the  towels  in  hot  1-2000  sublimate  or  1-20  carbolic  acid  solution, 
provided  they  are  not  wrung  dry.  On  the  whole  it  is  better,  whether  the 
towels  are  put  to  soak  first  of  all  in  a  1-20  carbolic  solution  or  not,  to 
wring  them  out  in  a  1-2000  sublimate  solution  before  they  are  laid  around 
the  operation  wound.  A  solution  of  1-20  carbolic  acid,  especially  if  it  be 
not  quite  pure  (as  is  commonly  the  case  if  obtained  from  the  ordinary 
chemist),  when  applied  to  the  skin,  is  apt  to  irritate  it,  and  may  be 
followed  by  absorption  of  the  drug,  whereas  this  does  not  occur  when  a 
1-2000  sublimate  solution  is  substituted. 

The  clothes  and  blankets  in  ^contact  with  the  patient  must  be  covered 
with  mackintoshes  (the  most  convenient  are  those  made  of  thin  jaconet),  and 
outside  these,  towels,  prepared  as  just  described,  should  be  spread  in  all 
directions,  so  that  nothing  can  by  any  chance  be  laid  on  septic  objects, 
such  as  blankets,  sheets,  etc.  During  the  operation  also  the  instruments 
should  be  handed  to  the  surgeon  direct  from  the  antiseptic  solution  in  which 
they  lie,  and  although  the  small  amount  of  carbolic  acid  which  might  enter 
the  wound  from  the  forceps,  knives,  etc.,  will  not  really  do  any  harm,  it  is 
as  well,  in  order  to  avoid  unnecessary  irritation,  to  rinse  the  instruments 
before  using  them  in  a  1-2000  sublimate  solution,  basins  of  which,  as  has 
already  been  mentioned,  should  always  be  standing  by  the  side  of  the 
operator  and  his  assistants.  After  an  instrument  has  been  used  it  should 
be  rinsed  in  the  sublimate  solution  before  being  again  employed.  A  word 
of  caution  may  be  given  concerning  the  manner  of  handing  ligatures  and 
sutures  to  the  surgeon.  It  is  too  frequently  the  custom  to  seize  the  ligature 
by  one  end,  and  hand  it  with  the  other  hanging  free.  The  consequence  is 
that,  if  the  thread  be  long,  its  free  end  is  very  likely  to  come  into  contact 
with  some  unpurified  object,  such  as  the  blanket  or  an  article  of  clothing, 
in  transit,  and  sepsis  may  thus  be  introduced  into  the  wound.  All  ligatures 
and  sutures  should  either  be  given  to  the  surgeon  with  the  free  end  coiled 
up  in  the  palm  of  the  hand,  or  one  end  should  be  taken  in  each  hand, 
and  special  care  taken  to  see  that  the  intervening  portion  does  not  touch 
any  unpurified  object.  Similarly,  when  there  is  a  large  wound  to  be  sewn 


166  WOUNDS. 

up,  and  the  surgeon  is  handed  a  long  suture  for  the  purpose,  it  is  a  good 
plan  to  keep  the  slack  of  the  thread  as  much  as  possible  in  the  basin  of 
lotion  at  the  side  of  the  field  of  operation,  used  for  dipping  the  hands,  etc., 
as  otherwise  it  is  often  difficult  to  keep  it  out  of  the  way  of  objects 
that  have  not  been  rendered  aseptic. 

Certain  precautions  as  to  dress  must  be  taken  by  the  surgeon  and 
his  assistants  in  order  to  avoid  accidental  contamination  of  the  wound 
during  the  course  of  an  operation.  The  sleeves  should  be  rolled,  pinned 
or  otherwise  fastened  up  well  above  the  elbow,  so  that  they  cannot  by 
any  chance  come  into  contact  with  the  wound.  This  is  a  much  better 
plan  than  that  of  wearing  "operating  sleeves"  or  cuffs,  which  is  somewhat 
common.  If  the  latter  are  worn  they  should  be  treated  in  precisely  the 
same  manner  as  the  antiseptic  towels  (see  above) ;  mackintosh  sleeves 
alone  should  never  be  worn  as  they  cannot  be  safely  rendered  aseptic. 
Most  surgeons  also  wear  some  form  of  operating  apron,  reaching  from 
above  the  collar  to  the  ground.  The  best  form  is  that  made  of  the  thin 
jaconet,  used  for  operation  mackintoshes,  and  it  should  be  well  washed 
over  with  the  strong  mixture  prior  to  commencing  the  operation.  As 
this  cannot,  however,  be  made  and  kept  aseptic  during  the  operation  with 
any  certainty,  and  as  some  part  of  it  is  very  likely,  especially  if  the 
surgeon  be  stout,  to  come  into  contact  with  instruments,  or  even  the  field 
of  operation  as  the  surgeon  bends  over  it,  it  is  well  to  have  in  addition 
one  of  the  antiseptic  towels  mentioned  above  (or  some  similar  contrivance) 
pinned  to  it  over  the  chest  and  abdomen.  Each  assistant  should  take 
precautions  similar  to  those  employed  by  the  surgeon. 

Management  of  Sponges. — The  sponges  when  removed  from  the  jar  in 
which  they  are  kept,  should  be  rinsed  in  a  1-2000  sublimate  solution,  and 
during  the  course  of  the  operation  they  should  never  be  washed  in  ordinary 
water.  When  they  have  become  soaked  with  blood  they  should  first  be 
squeezed  as  dry  as  possible,  then  rinsed  and  squeezed  thoroughly  in  a  cold 
1-2000  sublimate  solution,  and  placed  in  a  vessel  containing  a  similar  warm 
solution,  which  is  handed  to  the  surgeon.  The  surgeon  then  wrings  the 
sponge  dry  before  he  uses  it.  The  nurse  should  of  course  disinfect  her 
hands;  but,  as  she  is  constantly  soiling  them,  she  should  not  be  allowed  to 
wring  out  the  sponges  and  hand  them  dry  to  the  surgeon ;  this  is  an 
important  point  which  is  constantly  neglected. 

Avoidance  of  Aerial  Infection. — At  one  time  considerable  stress  was 
laid  upon  the  chance  of  wound  infection  by  the  air,  but  we  now  know  that 
the  organisms  generally  met  with  in  the  air  are  saprophytes,  which  do  not 
grow  in  the  tissues ;  in  fact,  they  are  non-parasitic  organisms.  Hence  the 
risk  from  organisms  falling  into  the  wound  from  the  air,  and  giving  rise 
to  trouble,  is  comparatively  slight.  At  the  same  time  it  must  be  admitted 
that  in  a  hospital  ward,  where  a  case  of  erysipelas  may  be  present,  there 
would  be  such  a  risk,  and  in  hospital  practice  there  must  always  be  a 
certain  degree  of  danger  from  this  source.  In  the  method  we  recommend 


TREATMENT   OF   INCISED   WOUNDS.  167 

any  aerial  organisms  which  come  in  contact  with  the  wound,  the  instruments, 
etc.,  are  rendered  inert  by  the  fact  that  they  fall  into  strong  antiseptic 
solutions,  for  even  although  all  the  spores  may  not  be  destroyed,  the  non- 
spore-bearing  organisms,  such  as  those  of  erysipelas,  would  at  once  be  killed. 
Irrigation  of  the  Wound. — With  a  view  of  still  further  effecting  this 
object  it  is  well,  as  an  additional  precaution,  to  douche  the  wound  from 
time  to  time  with  a  1-2000  sublimate  solution.  No  doubt,  theoretically, 
there  must  be  a  certain  amount  of  irritation  of  the  raw  surfaces  as  a 
result  of  this  procedure,  but  after  all  it  does  not  make  itself  manifest  in 
the  healing,  though  it  probably  might  do  so  were  a  1-20  or  a  1-40  carbolic 
acid  solution  employed  for  the  purpose.  In  operations  upon  healthy  joints, 
where  a  cavity  is  left  which  may  contain  blood  and  in  which  non-parasitic 
organisms  might  develop,  it  is  very  important  to  keep  a  stream  of  weak 
sublimate  (not  stronger  than  1-4000  watery  solution)  running  over  the 
wound.  In  ordinary  cases,  instead  of  squeezing  the  1-2000  solution  out 
of  the  sponge  into  the  basin,  it  suffices  now  and  then,  during  the  course  of 
the  operation,  to  squeeze  the  sponge  over  the  wound,  more  particularly 
while  the  stitches  are  being  inserted.  After  the  wound  has  been  stitched 
up,  judicious  pressure  will  expel  all  the  lotion  left  in  it. 


FIG.  51. — DEEP  SUTURE  FOR  APPROXIMATION  OF  MUSCULAR  PLANES.  This  stitch 
is  merely  an  applicat  on  of  MacEwen's  hernia  stitch.  The  method  of  passing  the  thread 
is  shown  in  the  sketch.  It  may  be  introduced  either  by  an  ordinary  surgical  needle  or, 
better,  by  the  handled  needle  shown  in  the  figure.  A  very  simple  plan  of  introducing  the 
suture  is  to  pass  the  needle  unthreaded  through  the  two  opposing  cut  surfaces,  pass  the 
thread  through  the  eye  and  withdraw  the  needle,  carrying  one  end  of  the  thread  with  it. 
This  leaves  the  needle  threaded  to  a  suture  which  traverses  both  lips  o_f  the  wound.  The 
threaded  needle  is  now  thrust  through  the  edge  of  the  incision  from  which  it  last  emerged, 
carried  across  the  wound,  made  to  pierce  the  opposite  side,  and  the  suture  unthreaded. 
The  needle  is  now  withdrawn,  leaving  the  loop  shown  above  in  situ.  This  is  not  the 
method  of  inserting  the  stitch  illustrated  above. 

Drainage. — After  the  operation  has  been  performed  with  the  various 
precautions  mentioned,  the  bleeding  is  arrested  by  one  of  the  methods 
already  described  (see  p.  128),  and  suitable  stitches  are  inserted  (see  p.  153). 


1 68 


WOUNDS. 


At  this  stage  the  question  of  drainage  arises.  When  Lord  Lister  began  his 
antiseptic  work  he  laid  very  great  stress  on  the  use  of  drainage,  and  at 
one  time  no  doubt  one  of  the  results  of  the  free  application  of  carbolic 
acid  to  wounds  was  a  very  marked  exudation  of  serum,  which,  if  not  allowed 
to  escape,  distended  the  wound  and  sometimes  caused  considerable  trouble 
in  healing.  But  with  the  introduction  of  sublimate  solution  and  the  avoid- 
ance of  carbolic  acid  in  the  wound,  the  conditions  underwent  a  change, 
and  at  the  present  time  it  is  only  comparatively  seldom  that  drainage  is 
required. 


FIG.  52. — DEEP  SUTURE  FOR  APPROXIMATION  OF  MUSCULAR  PLANES.  The  three 
sutures  are  tied.  The  sketch  shows  the  thick  ridge  formed  by  the  approximation  of  the 
tissues,  which  are  in  contact  over  a  comparatively  wide  area.  The  ends  of  the  sutures 
are  cut  short,  and  the  skin  is  afterwards  united  by  a  separate  continuous  suture. 

When  drainage  is  not  employed,  means  must  be  taken  to  bring  the 
deeper  parts  of  the  wound  into  apposition.  To  effect  this  some  surgeons 
introduce  stitches,  which  are  left  buried  in  the  wound.  This  may  sometimes 
be  necessary  where  many  muscular  planes  are  divided,  as,  for  instance, 
after  laparotomy  (the  most  suitable  form  of  stitch  for  which  is  shown  in  Figs. 
51  and  52),  exposure  of  the  kidney,  etc.,  but  as  a  general  rule  we  consider 
that  sponge  pressure  applied  outside  the  wound  is  sufficient.  By  one  or 
other  method,  however,  any  cavity  that  is  left  can  generally  be  obliterated, 
and  it  is  only  in  certain  cases  of  incised  wounds  made  by  the  surgeon 
that  this  is  impossible  ;  in  them,  drainage  tubes  are  required. 

Cases  calling  for  Drainage. — The  following  are  the  chief  conditions  in 
which  drainage  seems  desirable : 

(i)  In  amputation  wounds. — After  amputation  it  would  not  do  to  keep 
the  flaps  firmly  pressed  together  for  fear  of  interfering  with  their 
blood  supply,  while  it  would  be  equally  hurtful  to  allow  blood  to 
distend  them  and  possibly  lead  to  gangrene.  Therefore  it  seems 
advisable,  in  all  cases  of  amputation,  to  introduce  a  drainage  tube. 


TREATMENT   OF    INCISED   WOUNDS.  169 

(2)  Where  a  cavity  is  left. — For  example,  after  excision  of  one  half  of 

the  thyroid  gland  a  cavity  is  left  into  which  bleeding  is  very  apt 
to  occur,  for  pressure  cannot  be  applied  satisfactorily  without 
interfering  with  the  trachea;  in  these  and  similar  cases  the  tem- 
porary use  of  a  drainage  tube  is  advisable. 

(3)  Where  the  patient  is  spare. — In  these  subjects  the  skin  is  thin  and 

there  is  only  a  small  amount  of  subcutaneous  fat,  so  that  pressure 
could  not  be  employed  without  risk  of  sloughing. 

(4)  In  very  fat  people. — Wounds  in  very  stout  people  seem  to  fill  with 

oil,    and   this   apparently   interferes   with   the    proper    healing    of 

the  wound;  in  these  cases  also  it  is  well  to  employ  drainage. 
(5)    Where  there  is  a  risk  of  sepsis. — Drainage  should  always  be  employed 

where  a  sinus  or  ulcer  is  present  at  the  seat  of  operation,  lest  the 

attempt  to  disinfect  them  prove  unsuccessful. 

When  a  drainage  tube  is  introduced  it  need  not  extend  the  whole  length 
of  the  wound  so  long  as  it  passes  into  the  deeper  parts  of  it,  and  it  is 
well,  in  order  to  avoid  the  risk  of  displacement  of  the  tube,  to  stitch  the 
outer  end  to  the  edges  of  the  skin  after  cutting  the  tube  flush  with  the 
surface.  Drainage  tubes  need  not  be  left  in  a  wound  longer  than  three 
or  four  days  unless  sepsis  occurs.  If  it  be  desired  to  leave  a  particularly 
small  scar,  a  few  strands  of  horse-hair  or  catgut  (preferably  horse-hair),  or 
a  wisp  of  cyanide  gauze,  will  suffice  to  form  a  fine  capillary  drain. 

Dressings. — After  having  completed  the  operation,  stitched  up  the 
wound,  and  arranged  for  drainage  if  necessary,  the  next  point  is  the  appli- 
cation of  the  dressing.  The  blood  should  be  washed  away  from  the 
neighbourhood  of  the  wound  with  the  1-2000  sublimate  solution,  and  then 
a  suitable  antiseptic  dressing  applied.  It  is  as  well,  during  the  process  of 
washing  away  the  blood  from  about  the  wound,  etc.,  to  protect  the  wound 
from  infection  by  means  of  a  piece  of  cyanide  gauze  soaking  in  1-2000 
sublimate  solution  ;  this  is  removed  when  the  dressing  is  ready  to  be  applied. 
At  the  present  time  the  tendency  is  towards  the  use  of  dry  dressings,  which 
possess  two  great  advantages.  In  the  first  place,  the  blood  dries  quickly 
in  them  and  does  not  therefore  form  a  suitable  soil  for  the  development 
of  organisms,  and  consequently,  if  the  dressings  are  not  quite  aseptic,  or 
the  skin  be  not  completely  disinfected,  the  organisms  may  be  unable  to 
grow  and  reach  the  wound.  In  the  second  place,  the  dried  up  blood- 
stained dressings  adhere  to  the  skin  and  form  a  sort  of  splint,  which  keeps 
the  edges  of  the  wound  absolutely  at  rest. 

Lister's  Cyanide  Gauze. — The  most  universally  applicable  and  most 
satisfactory  dressing  yet  introduced  is  the  latest  dressing  proposed  by 
Lord  Lister,  viz.,  gauze  impregnated  with  the  double  cyanide  of  mercury 
and  zinc.  Certain  precautions  must  be  taken  in  using  this  dressing.  As 
supplied  from  the  manufacturer,  it  contains  an  amount  of  free  corrosive 
sublimate  which,  if  brought  in  contact  with  the  skin,  might,  in  delicate 
skins  at  any  rate,  lead  to  blistering.  Hence  the  free  sublimate  must  be 


170  WOUNDS. 

washed  out  before  the  dressing  is  used.  A  great  advantage  of  this  is 
that  it  gets  rid  of  an  objection  which  applies  to  all  dry  dressings  except 
those  disinfected  by  heat,  namely,  that  as  it  comes  from  the  makers  the 
dressing  may  contain  dust  and  organisms,  some  of  them  possibly  pathogenic ; 
it  is  well  therefore  to  disinfect  the  dressings  before  use  by  the  application 
of  some  antiseptic  solution.  With  the  object  therefore  both  of  dissolving 
out  the  free  sublimate  and  of  providing  an  aseptic  dressing,  it  is  well  to 
keep  the  cyanide  gauze  in  a  jar  of  1-40  or  1-60  carbolic  acid,  or,  where 
it  has  to  be  used  for  children  (who  are  very  susceptible  to  the  action  of 
carbolic  acid),  in  a  1-4000  or  1-6000  sublimate  solution.  The  dressing 
kept  in  this  solution  is  ready  for  use  at  any  time,  and  all  that  is  necessary 
is  to  wring  it  out  before  applying  it  to  the  wound.  As  no  impermeable 
layer,  such  as  mackintosh,  is  applied  outside  it,  the  gauze  quickly  dries, 
and  in  a  few  hours  a  perfectly  dry  dressing  is  formed.  In  applying  an 
antiseptic  dressing  large  quantities  should  be  used ;  there  should  be  no 
stint  whatever,  and  a  wide  area  of  skin  all  around  the  wound  should  be 
covered.  Besides  being  extensive  in  area,  the  dressing  should  also  be  of 
considerable  thickness,  some  12  to  20  folds  of  gauze  being  employed. 

Pressure. — Before  the  dressings  are  put  on,  the  superfluous  fluid  is 
squeezed  out  of  the  wound  and  then,  after  applying  the  first  few  folds  of 
the  gauze,  it  is  well  to  place  clean  sponges  wrung  out  of  the  antiseptic 
solution  over  the  area  of  the  wound,  so  as  to  approximate  the  deeper 
parts  and  prevent  the  formation  of  a  cavity.  Outside  the  sponges  more 
gauze  is  applied,  and  outside  this  again  a  mass  of  salicylic  wool  to 
increase  the  thickness  of  the  dressing.  Salicylic  wool,  although  said  to 
be  absorbent,  does  not  absorb  at  all  well,  and  the  object  in  employing 
it  is  not  so  much  to  furnish  an  additional  antiseptic  layer,  though  that 
is  an  important  point,  as  to  provide  a  material  which,  while  it  permits 
evaporation,  at  the  same  time  leads  to  a  diffusion  of  blood  and  serum 
over  a  considerable  area  of  the  cyanide  dressings.  As  a  matter  of  fact, 
however,  the  discharge  from  the  wound  is  usually  extremely  slight  where 
sponges  are  employed,  and  seldom  reaches  the  wool  at  all  Bandages 
are  applied  outside  the  salicylic  wool,  specially  firm  pressure  being  brought 
to  bear  over  the  sponges ;  and  in  certain  cases,  such  as  operations  for 
hernia,  or  on  the  neck,  etc.,  where  movements  of  the  thigh  or  of  the  head 
are  inevitable,  it  is  well  to  apply  a  piece  of  white  elastic  webbing  round 
the  edges  of  the  dressing  so  as  to  prevent  them  from  becoming  sepa- 
rated from  the  skin  by  the  movements  of  the  patient  (see  Figs.  53 
and  54). 

When  to  change  Dressings. — A  dressing  of  this  kind  is  usually  left 
undisturbed  for  about  ten  days,  unless  there  be  some  reason  for  changing 
it,  such  as  discomfort,  fever,  the  presence  of  a  drainage  tube,  or  any  suspicion 
of  sepsis.  It  is  a  mistake  to  change  a  dressing  soon  after  the  operation 
unless  it  be  really  necessary,  because  the  dressing  adheres  to  the  skin, 
and,  in  pulling  it  off,  the  union  of  the  deeper  parts  may  be  disturbed. 


TREATMENT   OF    INCISED   WOUNDS. 


171 


and  bleeding  may  even  occur  into  them.     The  following  are  the  principal 
cases  in  which  an  early  change  of  dressing  is  called  for : 

(i)  In  some  cases,  the  dressings  as  they  dry  become  hard  and 
uncomfortable,  and  in  sensitive  patients  therefore  it  is  often 
advisable  to  change  them  at  the  end  of  three  or  four  days;  the 
second  dressing  never  becomes  so  hard  and  uncomfortable  as 
the  first. 


FIG.  53. — METHOD  OF  EMPLOYING  ELASTIC  PRESSURE  TO  KEEP  DRESSINGS  IN 
POSITION.  The  sketch  shows  a  front  view  of  the  dressings  we  usually  apply  after  hernia 
operations,  and  illustrates  the  method  of  applying  the  elastic  webbing ;  this  is  stretched 
fairly  tight,  and  is  still  further  prevented  from  slipping  by  the  safety  pins  shown  in  the 
figure. 


FIG.  54. — METHOD  OF  EMPLOYING  ELASTIC  PRESSURE  TO  KEEP  DRESSINGS  IN 
POSITION.  This  is  a  sketch  of  the  same  dressing  as  in  Fig.  53,  but  seen  from  below.  It 
shows  the  manner  in  which  the  webbing  crosses  in  the  perineum. 

(2)  When  the  amount  of  discharge  from  the  wound  is  excessive.  The 
old  rule  that  dressings  required  changing  very  soon  after  discharge 
showed  itself  through  them  is  not  now  applicable ;  as  a  matter 
of  fact,  it  is  not  uncommon  with  the  dressings  just  described,  where 
no  mackintosh  is  applied  on  the  outside,  for  a  little  blood  to 


i;2  WOUNDS. 

appear  at  the  edge  within  a  few  hours  after  the  operation ;  but 
this  very  quickly  dries  up  and  does  not  form  a  cultivating  medium 
for  the  growth  of  the  bacteria,  because  the  double  cyanide  salt  is 
a  powerful  inhibitory  agent  against  their  growth,  and,  being  only 
slightly  soluble,  is  not  washed  out  by  the  first  blood  which  passes 
through  the  dressing.  All  that  is  necessary  is  to  sprinkle  some 
iodoform  over  the  soiled  portion,  to  apply  fresh  salicylic  wool 
outside  this,  and  to  secure  it  by  another  bandage.  At  the  same 
time,  if  the  discharge  be  very  free  at  first,  it  may  be  desirable  to 
change  the  dressing  after  24  or  48  hours. 

(3)  When   a   drainage  tube   has   been   inserted,  the   dressings   must   be 

changed  at  the  end  of  four  or  five  days  in  order  to  remove  it; 
if  the  wound  be  large,  the  discharge  through  the  tube  may  be 
sufficiently  copious  to  necessitate  a  change  of  dressing  at  the  end 
of  24  or  48  hours. 

(4)  If  after  the  operation  the  temperature  rise  and  remain  over  100°  F. 

for  more  than  24  hours,  or  if  there  be  much  pain,  the  dressing 
must  be  removed  to  see  if  anything  is  wrong  with  the  wound. 

How  to  change  them. — When  the  dressings  are  changed  at  the  end  of 
about  ten  days,  the  wound  is  usually  soundly  healed ;  the  stitches  are 
then  taken  out,  and  a  small  piece  of  gauze  or  salicylic  wool  is  fixed  over 
the  line  of  incision  for  a  few  days  by  means  of  collodion.  In  changing 
dressings  it  is  well  to  employ  a  1-2000  sublimate  solution  to  wash  the 
wound,  except  in  operations  in  the  axilla,  the  perineum,  or  about  the 
pubes,  etc.,  where,  on  account  of  the  proximity  of  hairy  parts,  it  is  advisable 
to  wash  the  skin  around  the  wound  thoroughly  with  a  1-20  carbolic  lotion. 
The  region  of  the  wound  should  be  surrounded  by  towels  wrung  out  of 
the  antiseptic  solution,  so  that,  should  the  patient  move,  the  blankets  do 
not  come  into  contact  with  the  wound,  the  instruments,  or  the  surgeon's 
hands.  The  latter  are  disinfected  in  a  1-20  carbolic  acid  lotion,  and  sub- 
sequently in  the  1-2000  sublimate  solution.  Salicylic  wool  is  a  very  good 
material  with  which  to  wash  the  part,  and  in  doing  this  it  is  not  necessary 
to  rub  the  wound.  If  the  latter  has  not  quite  healed,  or  if,  on  account 
of  tension  upon  the  edges,  it  seems  advisable  to  leave  any  of  the  stitches 
in  place  for  some  time  longer,  a  dressing  similar  to  that  put  on  immedi- 
ately after  operation  (see  p.  169)  may  be  re-applied,  the  only  difference 
being  that  the  sponges  need  not  be  again  employed.  In  breast  cases, 
for  instance,  where  a  large  amount  of  skin  has  been  taken  away,  it  is 
often  advisable  to  change  the  first  dressing  before  the  end  of  the  first  week, 
in  order  to  remove  some  of  the  stitches  and  clean  the  axilla ;  the  remaining 
stitches  may  then  be  left  for  another  week,  when  they  can  be  removed. 

After-progress  of  the  Wound. — In  operations  conducted  with  all 
the  precautions  recommended  above,  it  will  be  found  that  neither  local 
nor  constitutional  disturbance  follows.  In  the  case  of  a  very  severe  opera- 
tion, the  temperature  is  at  first  sub-normal,  the  patient  suffers  from  a 


TREATMENT   OF    INCISED   WOUNDS. 


173 


certain  amount  of  shock  for  some  hours,  and  this  is  followed,  to  an  extent 
closely  corresponding  to  the  degree  of  shock,  by  a  certain  amount  of 
reaction,  so  that  next  day  the  temperature  may  be  up  to  100°,  or  even 
to  ioi°F.  At  the  same  time,  however,  the  pain  complained  of  immedi- 
ately after  the  operation  subsides,  and  there  is  no  fresh  development  of  it, 
as  would  be  the  case  were  the  temperature  due  to  sepsis.  In  the  course 
of  another  twelve  to  twenty-four  hours  the  temperature  falls  rapidly  to 
normal. 

Treatment  without  Antiseptics. — The  other  plan,  to  which  we 
have  already  referred  (see  p.  161),  in  which  attempts  are  made  to  keep 
wounds  aseptic  without  the  use  of  antiseptic  lotions  and  dressings,  is  theo- 
retically good,  but  practically  it  does  not  yield  the  results  which  are  obtained 
by  the  method  just  described.  It  consists  in  the  entire  avoidance  of  the 
use  of  antiseptics  during  the  actual  performance  of  the  operation,  and  in 
the  after-treatment  of  the  wound.  The  skin  is  purified,  and  the  hands  of 
the  assistant  and  the  operator  are  disinfected  very  much  in  the  manner 
already  described  (see  p.  161).  The  instruments  are  boiled,  but  are  not 
afterwards  immersed  in  antiseptics,  and  there  is  no  antiseptic  solution  at 
hand  to  douche  the  wound;  the  swabs  consist  of  pieces  of  wool  disin- 
fected by  heat  and  used  dry,  and  the  towels  placed  around  the  operation 
area  are  also  dry,  and  have  been  previously  disinfected  by  heat.  There 
is  therefore  no  possibility  of  correcting  any  accident  that  may  happen 
during  the  operation,  such  as  dust  falling  on  the  towels,  or  the  un- 
observed contact  of  the  hand  with  any  object  that  has  not  been 
disinfected.  The  dressings  consist  for  the  most  part  of  simple  absorbent 
unmedicated  wool,  which  is  disinfected  by  heat,  the  box  or  bag  in  which 
the  wool  is  disinfected  being  only  opened  at  the  side  of  the  patient  by 
the  surgeon  himself;  it  is  obvious  that  the  greatest  care  is  required  in 
handling  these  if  accidental  contamination  is  to  be  avoided.  In  the 
"antiseptic"  or  Listerian  plan,  which  is  the  one  we  have  recommended, 
these  accidents,  if  they  do  occur,  may  be  automatically  remedied,  because 
everything  is  being  frequently  soaked  in  antiseptic  solutions.  In  the 
so-called  "aseptic"  plan  there  is  no  corrective  for  these  accidents  at  all, 
and,  consequently,  experience  shows  that  the  results  are  not  equal  to  those 
of  the  other  method. 

No  doubt,  theoretically,  it  ought  to  be  possible  to  carry  out  this 
aseptic  plan,  and  if  it  were  found  in  practice  that  the  use  of  antiseptics 
gave  rise  to  great  irritation  in  wounds,  the  employment  of  a  cumbrous 
and  troublesome  method,  such  as  the  so-called  "aseptic"  one,  would  be 
justified.  As  a  matter  of  fact,  however,  the  irritation  of  wounds  from  such 
antiseptics  as  we  have  recommended  is  inappreciable,  and  there  is  not 
the  least  reason  for  the  introduction  of  this  troublesome  method,  more 
particularly  as  the  results  obtained  by  it  are  not  so  good.  The  method 
can  only  be  carried  out  by  a  skilled  and  experienced  bacteriologist, 
with  all  the  resources  of  a  large  and  well-equipped  hospital  at  his 


174  WOUNDS. 

command.  In  ordinary  private  practice,  not  only  is  it  almost  impossible 
to  carry  it  out  in  all  its  details,  but,  as  a  single  error  may  invalidate 
the  whole  proceeding,  and  as  no  corrective  is  possible,  the  plan  may  be 
positively  harmful. 

Causes  of  Failure  to  secure  Healing  by  First  Intention. — 
Where  all  the  steps  of  the  antiseptic  method  have  been  rigidly  adhered 
to,  there  is  very  seldom  failure  to  obtain  healing  by  first  intention.  When 
it  does  not  occur,  it  is,  in  the  majority  of  cases,  because  some  error  has 
been  committed  in  the  management  of  the  case,  which  has  led  to  the 
occurrence  of  sepsis.  Sometimes,  however,  union  may  fail,  in  part  at  any 
rate,  notwithstanding  the  fact  that  the  wound  remains  aseptic.  Perhaps 
the  most  common  cause  of  this  is  the  accumulation  of  serum  in  the  deeper 
parts  of  the  wound;  these  are  cases  in  which  a  drainage  tube  should  have 
been  employed.  If  accumulation  does  take  place,  it  is  better  to  evacuate 
the  serum  than  to  wait  in  the  hope  that  it  will  be  absorbed ;  doubtless 
this  sometimes  occurs,  but  in  the  majority  of  cases  it  will  find  its  way  out 
along  the  line  of  incision.  Wherever,  therefore,  it  is  found  at  the  first 
dressing  that  there  is  a  collection  of  fluid  in  the  wound,  time  is  really 
saved  by  opening  up  the  incision  with  a  pair  of  sinus  forceps,  letting  out 
the  fluid  and  introducing  a  small  drainage  tube,  which  should  be  left  in 
for  two  or  three  days.  The  fluid  will  be  found  to  be  merely  serum  or 
altered  blood,  and  when  a  drainage  tube  is  introduced  and  pressure  applied 
outside,  the  wound  closes  very  quickly. 

Mention  has  already  been  made  of  the  importance  of  putting  in  a 
sufficient  number  of  stitches  to  prevent  gaping  of  a  wound,  and  also  of 
not  tying  them  so  tightly  that  they  will  cut  through  the  skin.  If  a  sufficient 
number  of  stitches  has  not  been  employed,  the  tension  on  any  individual 
stitch  may  be  so  great  that  it  will  cut  its  way  through  the  skin  and  allow 
a  portion  of  the  wound  to  gape.  Movement  of  the  part  also  interferes 
sometimes  with  primary  union,  and  in  other  instances  the  cause  of  non- 
union may  be  that  the  knife  has  been  held  obliquely  in  making  the  skin 
incision;  the  bevelled  edge  of  skin  thus  left  on  one  side  often  dies.  In 
most  cases,  however,  when  union  fails,  it  is  owing  to  the  presence  of  sepsis, 
and  if  suppuration  occur  in  a  wound  made  by  the  surgeon  through  unbroken 
skin,  the  surgeon  himself  is  entirely  to  blame  for  its  occurrence.  Whether 
it  be  that  he  has  used  impure  materials  for  his  ligatures  or  stitches,  or 
whether,  as  is  commonly  the  case,  he  or  his  assistants  have  introduced 
the  organisms  with  their  hands,  he  is  equally  responsible.  This  fact  cannot 
be  too  widely  appreciated. 

Errors  which  may  be  made  in  carrying  out  the  antiseptic  treatment  of 
wounds  have  already  been  described,  but  it  is  quite  impossible  to  point 
out  all  the  extraordinary  mistakes  which  are  daily  committed.  All  that 
can  be  said  with  regard  to  them  is  that,  unless  the  surgeon  constantly 
bears  in  mind  the  fact  that  nothing  that  has  not  been  made  aseptic  must 
come  in  contact  either  with  the  wound,  the  instruments,  or  the  hands  that 


TREATMENT   OF    INCISED    WOUNDS.  175 

are  introduced  into  the  wound,  he  will  be  sure  eventually  to  go  wrong. 
A  preliminary  bacteriological  training  is  of  incalculable  advantage,  for  with 
it  the  manipulations  necessary  to  secure  asepsis  become  automatic,  and  the 
surgeon  is  thus  enabled  to  concentrate  his  undivided  attention  upon  the 
operation. 

Treatment  where  Sepsis  occurs. — When,  in  spite  of  all  efforts  to 
prevent  it,  sepsis  occurs,  its  onset  is  indicated  by  pain  and  throbbing  in 
the  wound.  The  reactionary  temperature  commonly  met  with  after  severe 
aseptic  operations,  instead  of  falling  in  from  24  to  36  hours,  continues  to 
rise,  and  all  the  symptoms  of  pyrexia  set  in.  Whenever  this  febrile  con- 
dition is  established,  the  wound  should  be  at  once  examined,  and  if  red, 
tender,  or  swollen,  it  should  be  opened  up,  at  any  rate  at  the  most  dependent 
spot,  and  proper  drainage  provided.  As  a  rule  it  is  not  advisable  to  wash 
out  a  wound  in  this  condition,  although  it  is  done  by  many  surgeons. 
Washing  out  a  septic  wound  with  antiseptics  will  not  arrest  the  infection, 
and  the  only  effect  it  can  produce  is  to  irritate  and  damage  the  inflamed 
tissues,  and  possibly  to  precipitate,  or  at  any  rate  to  facilitate,  the  entrance 
of  micro-organisms  into  the  system.  Provided  there  be  a  free  exit  for  pus, 
it  is  best  not  to  wash  or  squeeze  out  or  in  any  way  irritate  the  wound. 
The  only  exception  to  this  rule  is  in  the  case  of  large  cavities,  where  there 
is  reason  to  believe  that  the  symptoms  are  mainly  due  to  septic  intoxication, 
that  is  to  say,  absorption  of  poisonous  chemical  products  and  not  true 
general  bacterial  infection.  Under  such  circumstances  it  is  well  to  wash 
away  the  septic  fluid  in  the  wound  with  sterilised  water  or  with  some  very 
weak  antiseptic  solution,  such  as  1-4000  or  6000  sublimate  solution,  not 
with  the  view  of  killing  bacteria,  but  of  removing  the  poisonous  chemical 
products  which  are  being  absorbed,  and  are  producing  the  symptoms.  It 
is  well  to  go  on  with  the  antiseptic  dressings  already  described  (see  p.  169), 
but  they  should  now  be  changed  daily. 

Where  no  general  infection  has  occurred,  or  is  about  to  take  place,  the 
temperature  falls,  and  the  other  general  and  local  conditions  improve  within 
a  few  hours  after  a  free  exit  has  been  provided  for  the  discharge.  In  the 
course  of  a  few  days  suppuration  ceases  and  the  discharge  becomes 
serous,  and  if  everything  goes  well,  the  drainage  tube  may  be  left  out  in 
from  10  to  14  days.  Where,  on  the  other  hand,  the  temperature  keeps  up 
and  the  other  symptoms  continue,  the  suspicion  is  aroused  either  that  there 
is  some  recess  in  the  wound  from  which  the  discharge  is  not  properly 
escaping,  or  that  some  general  infection  is  occurring.  In  either  case  the 
wound  must  be  thoroughly  and  completely  opened  up  and  cleansed,  all 
recesses  must  be  freely  exposed,  and,  especially  where  there  is  not  sufficient 
retention  of  discharge  to  account  for  the  general  symptoms,  the  wound 
should  be  thoroughly  sponged  out  with  undiluted  carbolic  acid.  In  some 
cases  the  surgeon  may  even  venture  to  scrape  away  the  granulation  tissue 
with  a  sharp  spoon,  but  in  doing  this  there  is  always  a  certain  risk  of 
forcing  organisms  into  the  circulation.  If  it  be  done,  one  of  Barker's 


176  WOUNDS. 

flushing  spoons  (see  Fig.  55)  should  be  employed,  the  fluid  used  for  irri- 
gation being  a  1-4000  sublimate  solution.  After  the  wound  has  been 
thoroughly  sponged  out  with  liquefied  carbolic  acid,  it  should  be  stuffed 
with  cyanide  gauze  freely  sprinkled  with  iodoform,  and  made  to  heal  by 
granulation  from  the  bottom,  the  stuffing  being  renewed  once  or  even  twice 
daily  if  the  suppuration  persist.  If,  as  the  result  of  this  procedure,  the 
temperature  fall  and  the  general  disturbance  subside,  it  may  be  possible 
in  three  or  four  days  to  discontinue  the  stuffing,  and,  after  introducing  a 
drainage  tube,  to  stitch  up  the  edges  of  the  wound  again. 


FIG.  55. — BARKER'S  FLUSHING  SPOON.  This  is  a  hollow  sharp  spoon  which  is  con- 
nected with  a  reservoir  of  fluid  by  means  of  india-rubber  tubing  attached  to  the  handle 
(the  attachment  is  shown  at  the  right-hand  end  of  the  figure).  The  passage  of  the  fluid  is 
regulated  by  the  sliding  valve  seen  on  the  upper  surface. 

When  the  occurrence  of  rigors,  and  sudden  elevations  of  temperature, 
lead  one  to  suspect  pyaemia,  it  is  important  in  opening  up  the  wound 
to  look  carefully  for  any  thrombosed  veins,  and  should  any  be  found, 
the  main  vein  above  the  thrombosed  area  should  be  ligatured,  and  a 
portion  excised  in  order  to  cut  off  the  local  source  of  infection  from 
the  general  circulation.  When  the  constitutional  symptoms  persist  in 
spite  of  this  energetic  local  treatment,  nothing  remains  to  be  done  but 
to  treat  the  patient  on  general  principles,  the  strength  being  supported 
by  stimulants,  and  a  diet  as  nutritious  as  he  is  able  to  digest  being  ad- 
ministered. Where  the  temperature  is  excessively  high,  it  may  be  kept 
down  by  quinine  or  other  febrifuges,  or  by  the  employment  of  cold  sponging 
or  cold  baths ;  the  state  of  the  excretions  should  be  carefully  attended 
to.  These  matters  will  be  referred  to  more  in  detail  when  we  come  to 
speak  of  the  treatment  of  Pyaemia  (see  Chap.  X.).  The  only  thing  of  any 
service  in  the  local  treatment,  when  the  general  symptoms  persist,  is  to 
continue  stuffing  the  wound  with  gauze  impregnated  with  iodoform  ;  some- 
times when  there  is  diffuse  cellulitis  in  the  neighbourhood,  constant  irrigation 
may  be  employed,  to  wash  away  the  septic  material  as  soon  as  it  is  formed. 
The  methods  of  irrigating  wounds  have  already  been  described  under  the 
head  of  Diffuse  Cellulitis  (see  p.  30). 

Treatment  of  Wounds  where  the  Edges  are  not  brought 
together.— We  have  still  to  consider  another  class  of  wounds,  made  by 
the  surgeon  through  unbroken  skin,  those,  namely,  where  it  is  quite  impossible, 
in  spite  of  any  freeing  of  the  edges,  to  bring  the  margins  of  the  skin  together, 
and  where,  therefore,  an  open  wound  must  be  left.  Here  also  it  is  im- 
portant that  organisms  should  be  excluded,  and  if  this  be  successfully 
accomplished,  and  steps  taken  to  keep  the  part  absolutely  at  rest  and 
to  prevent  irritation  by  the  dressings,  the  space  between  the  edges  fills 
up  with  blood,  and  healing  by  blood-clot  will  occur.  To  obtain  this 


TREATMENT   OF   INCISED   WOUNDS.  177 

result,  similar  methods  and  dressings  should  be  employed  to  those  used 
where  the  edges  are  brought  together;  but,  in  order  to  protect  the  blood- 
clot  from  the  irritation  of  the  dressings,  a  piece  of  Lister's  oiled  silk  protective, 
somewhat  larger  than  the  wound,  should  be  interposed;  the  protective 
is  soaked  in  the  sublimate  solution  for  some  time  previous  to  application, 
and  outside  it  a  large  gauze  and  wool  dressing  is  applied.  What  most 
commonly  happens  where  the  wound  is  large  is  that  healing  by  blood- 
clot  occurs  to  a  considerable  extent,  and  then  a  small  part  in  the  centre 
undergoes  a  certain  amount  of  granulation  before  complete  cicatrization 
takes  place. 

Thiersch's  Skin-grafting  in  Fresh  Wounds. — Healing  by  blood-clot  is, 
however,  a  slow  process,  and  there  is  always  a  risk  of  accidental  contamination 
of  the  wound;  therefore,  a  quicker  method  of  obtaining  healing,  namely, 
Thiersch's  skin-grafting,  is  often  employed.  By  its  adoption  immediately 
after  the  infliction  of  the  wound,  a  good  result  will  be  obtained  in 
most  cases,  and  healing  will  occur  almost  as  rapidly  as  in  union  by 
first  intention,  while  the  contraction  which  follows  granulation  will,  to  a 
great  extent  be  avoided.  Skin-grafting  should  be  employed,  if  possible, 
at  the  end  of  the  operation,  as  soon  as  the  bleeding  has  been  arrested, 
and,  with  the  exception  that  in  these  cases  there  is  no  granulating  wound 
to  scrape,  the  whole  process  is  the  same  as  that  already  described  on  p.  50. 
Where  the  operation  has  been  very  extensive,  and  the  patient  is  very 
collapsed,  it  may  be  advisable  to  defer  the  skin-grafting  for  a  short  time; 
in  these  cases,  after  about  ten  days,  the  blood-clot  is  scraped  from  the 
surface  of  the  wound,  and,  when  the  oozing  has  been  arrested,  the  skin-grafts 
are  applied  in  the  usual  manner.  At  first  sight,  it  might  be  supposed 
that  the  skin-grafts  would  not  adhere  well  to  non-granulating  tissues,  but 
as  a  matter  of  fact  they  do,  and  much  may  be  done  to  improve  the  condition 
of  affairs  by  immediate  skin-grafting, 

Plastic  Operations. — Where  the  cutaneous  loss  is  not  excessive,  and 
the  skin  in  the  neighbourhood  is  fairly  lax,  the  interval  between  the  edges 
of  the  wound  may  be  made  good  by  means  of  a  plastic  operation.  By  a 
plastic  operation  is  meant  one  performed  with  the  view  of  covering  in  some 
defect  in  the  skin,  mucous  membrane,  etc.,  whether  congenital  or  acquired. 
In  the  present  instance  we  have  only  to  do  with  the  covering  in  of 
defects  left  after  an  operation  in  which  the  edges  of  the  wound  cannot 
be  brought  together.  The  plastic  operations  in  connection  with  congenital 
defects  will  be  dealt  with  in  their  proper  place. 

The  simplest  form  of  defect  is  an  oval  wound,  and  here  the  steps 
necessary  to  bring  the  edges  into  apposition  are  generally  very  simple.  All 
that  is  necessary  in  most  cases  is  to  undermine  the  skin  around  the  wound 
for  a  sufficient  distance  to  allow  the  elasticity  of  the  skin  sufficient  play. 
A  very  extensive  oval  defect  may  be  repaired  in  this  manner;  in  removal 
of  the  breast,  for  example,  an  interval  of  twelve  inches  or  more  may  be 
closed  by  undermining  the  skin. 

M 


178  WOUNDS. 

The  plan  of  undermining  the  skin  has  already  been  mentioned  (see  p.  157), 
but  we  may  here  give  fuller  details  of  the  method.  The  best  way  is  to 
proceed  as  follows.  In  small  wounds,  the  knife  is  carried  between  the 
superficial  fat  and  the  deep  fascia;  in  extensive  ones,  it  should  be  swept 
between  the  deep  fascia  and  the  muscle,  and  by  this  means  the  skin  and 
fascia  are  raised  from  the  deeper  parts  for  a  considerable  distance  around 
the  wound.  The  undermining  should  be  most  extensive  opposite  the 
shortest  diameter  of  the  oval,  and  should  be  carried  on  until  the  edges 
of  the  wound  can  easily  be  brought  into  contact  by  pulling  upon  them. 
In  raising  these  flaps,  great  care  must  be  taken  to  direct  the  edge  of  the 
knife  towards  the  deeper  parts  and  not  towards  the  skin ;  failure  to  observe 
this  precaution  is  apt  to  result  in  scoring  of  the  flap,  and,  as  the  blood- 
vessels which  supply  the  skin  ramify  in  the  subcutaneous  fat,  the  blood 
supply  to  the  edges  of  the  wound  might  be  cut  off  and  sloughing 
might  ensue.  The  freeing  of  the  edges  of  the  wound  by  undermining 
must  be  carried  out  sufficiently  widely  to  allow  them  to  come  together 
without  endangering  the  circulation  in  the  flaps.  If  it  has  not  been  done 
sufficiently  freely,  the  flaps  will  become  white  on  putting  in  the  stitches, 
and  after  waiting  a  little  the  circulation  will  not  be  restored ;  it  will,  therefore, 
be  necessary  in  such  a  case  to  carry  the  undermining  further,  when  the 
flaps  may  be  brought  together  without  being  permanently  blanched. 
If  at  first  there  be  a  little  whiteness  in  the  immediate  vicinity  of  the 
stitch,  it  will  disappear  in  a  few  minutes  when  the  tension  is  not  too 
great  Deep  stitches  and  sometimes  button  stitches  should  be  used  so 
as  to  relax  the  edges  in  order  that  there  may  be  no  tension  upon  the 
actual  line  of  union. 

Where  the  wounds  are  angular,  or  quadrilateral,  or  irregular  in  shape, 
they  require  for  their  closure  one  of  the  plastic  operations  proper.  The 


04  c  C  D  d 

FIG.  56.  FIG.  57. 

FIG.  56. — PLASTIC  OPERATIONS.  How  to  fill  up  a  quadrilateral  defect  of  moderate 
size.  By  carrying  incisions  horizontally  outwards  from  £  to  6  and  from  D  to  d,  a.  flap 
BDdb,  can  be  dissected  up  and  pulled  inwards  so  that  the  edge  B  D  comes  into  con- 
tact with  and  is  sutured  to  A  C.  The  incisions  B  b  and  D  d  should  be  longer  in 
proportion  to  A  B  and  C  D  than  are  here  represented. 

FIG.  57. — PLASTIC  OPERATIONS.  How  to  fill  up  a  quadrilateral  defect  of  large 
size.  Here,  by  a  similar  procedure  to  that  shown  in  Fig.  56,  a  flap  is  dissected  up  on  each 
side  of  the  defect.  The  two  flaps  are  then  pulled  inwards  to  the  middle  line,  and  A  C  is 
sutured  to  B  D. 

simplest  of  these  is  perhaps  a  small  quadrilateral  defect;  this  is  very 
easily  filled  up  by  making  incisions  which  extend  the  corresponding  sides 
of  the  parallelogram  straight  into  the  healthy  skin  on  one  side,  that  is  to 
say,  in  Fig.  56,  the  side  AB  is  extended  to  b  and  CD  to  d.  The  flap 
BDdb,  which  ought  generally  to  be  about  double  the  length  of  the  side 


TREATMENT   OF   INCISED   WOUNDS.  179 

AB,  is  then  dissected  up  along  with  the  subcutaneous  tissue.  When 
dissected  up  in  this  way,  the  elasticity  of  the  skin  allows  the  flap  to  be 
stretched  with  comparatively  slight  tension,  so  that  the  point  B  may  be 
stitched  to  the  point  A,  and  the  point  D  to  the  point  C, 

Where  the  quadrilateral  defect  is  larger,  it  can  be  closed  by  making 
similar  incisions  on  the  opposite  side  also,  that  is  to  say,  in  Fig.  57,  by 
extending  the  side  AB  both  to  b  and  to  a,  and  similarly  CD  to  both 
d  and  c.  Two  flaps,  ACca  and  BDdb,  are  thus  marked  out,  one  on 
each  side,  and  when  they  are  dissected  up  they  can  generally  be  made 
to  meet  in  the  middle  of  the  defect  and  can  be  stitched  together. 

Where  the  defect  is  triangular,  say  an  equilateral  triangle,  and  the  raw 
area  is  small,  it  may  suffice  to  make  an  incision  which,  in  Fig.  58,  extends 


c 

FIG.  59. 

FIG.  58. — PLASTIC  ^OPERATIONS.  How  to  fill  up  a  triangular  defect  of  moderate  size. 
By  carrying  an  incision  from  B  to  b,  a  flap  C  Bb  can  be  raised,  so  as  to  allow  the  side 
C  B  to  be  pulled  towards  and  stitched  to  the  side  C  A.  The  incision  Bb  should  be 
nearly  double  the  length  of  A  B. 

FIG.  59. — PLASTIC  OPERATIONS.  How  to  fill  tip  a  triangular  gap  of  large  size. 
The  dotted  lines  show  the  incisions  made  to  allow  two  flaps  to  be  raised.  When  this  is 
done,  A  C  and  B  C  are  approximated  and  stitched  together. 

the  side  AB  to  one  side  only,  the  extension  being  about  double  the  length 
of  the  side  AB.  The  triangular  flap  thus  marked  out  is  dissected  up 
along  with  the  fat,  when  the  point  B  can  generally  be  stitched  to  the  point 
A.  If,  however,  the  defect  be  large,  the  sides  may  be  made  to  meet  by 
forming  a  second  similar  flap  on  the  other  side,  that  is  to  say,  in  Fig.  59, 
by  extending  the  line  AB  on  the  one  side  in  the  direction  of  A,  and  on 
the  other  side  in  the  direction  of  B.  These  two  flaps  will  then  meet  in 
the  middle  line  and  can  be  sewn  together. 

In  many  cases,  however,  especially  where  the  triangular  space  is  large, 
the  incisions  for  the  flaps  should  be  curved,  and,  in  the  case  of  irregular 


N  b 


FIG.  60. — PLASTIC  OPERATIONS.  To  fill  in  a  triangular  defect  by  means  of  curved 
incisions.  By  carrying  a  curved  incision  from  B  outwards  to  b,  and  one  from  A  to  a,  the 
flaps  thus  formed  can,  after  they  have  been  dissected  up,  be  made  to  slide  inwards  so  as 
to  approximate  A  C  and  C  B  with  much  greater  ease  than  if  straight  incisions  had  been 
used. 

defects,  the  great  secret  of  successful  plastic  operations  is  to  use  curved 
incisions.  Much  better  results  will  be  obtained  by  the  use  of  curved  incisions 
than  by  straight  ones.  When  it  is  necessary  to  remove  the  lower  lip,  this 
is  usually  done  by  taking  out  a  V-shaped  piece,  the  apex  of  the  V  being 


l8o  WOUNDS. 

towards  the  chin.  To  fill  the  gap  a  large  curved  incision  should  be  made, 
beginning  at  the  angle  of  the  mouth,  running  down  over  the  jaw  on  to 
the  neck,  and  curving  inwards  towards  the  upper  part  of  the  larynx ; 
where  the  whole  lip  is  removed  a  similar  curved  incision  is  made  on 
each  side.  The  incision  goes  through  the  whole  thickness  of  the  cheek  ; 
when  it  passes  on  to  the  neck,  the  skin  and  superficial  fascia  alone  are 
dissected  up.  When  the  flaps  have  been  raised  sufficiently,  the  curved 
incisions  allow  them  to  slide  inwards,  so  that  the  two  sides  of  the  triangular 
defect  meet  in  a  vertical  line,  and  may  be  stitched  together;  a  few  points 
of  suture  are  then  put  in  along  the  curved  lines  of  incision  (see  Fig.  60). 

We  need  not  here  go  into  detail  as  to  the  covering  in  of  irregular  defects, 
or  of  those  in  special  situations.  They  will  be  treated  of  later  on  as  occa- 
sion arises.  The  great  principle  to  which  we  wish  to  call  attention  is  that, 
where  the  surgeon  has  to  do  with  large  defects  of  skin,  curved  incisions 
will  enable  him  to  close  the  defect  with  much  greater  ease  and  less  extensive 
dissection  than  if  straight  incisions  alone  were  employed. 

Use  of  Granulating  Flaps. — Where  there  are  very  large  defects,  and 
where  the  flaps  to  be  turned  in  would  be  very  long  and  have  a  com- 
paratively narrow  base,  in  other  words,  where  the  blood  supply  would 
necessarily  be  imperfect,  it  has  been  recommended  that  the  flap  should 
be  dissected  up  but  left  attached  at  each  end,  and  that  both  it  and  the 
wound  should  be  allowed  to  granulate  before  the  actual  transplantation 
of  the  flap  takes  place.  The  reason  for  this  suggestion  is  that,  by  dissecting 
up  the  flap  but  leaving  it  attached  at  both  ends,  it  is  more  likely  to  retain 
its  vitality,  while  new  blood-vessels  and  a  more  perfect  blood  supply  are 
developed  during  the  process  of  granulation. 

In  this  plan  the  flaps  are  usually  made  more  or  less  quadrilateral, 
and  their  two  ends  are  not  detached.  After  disinfection  of  the  skin, 
lateral  incisions  are  made  down  to  the  deep  fascia,  and  then  the  flap 
is  undermined  throughout  its  whole  extent,  so  that  the  finger  can  readily 
be  passed  under  it  in  all  directions.  A  piece  of  protective,  dipped  in  a 
1-2000  sublimate  solution,  is  then  inserted  between  the  under  surface  of 
the  flap  and  the  deeper  structures,  and  this  is  kept  in  place  for  from 
ten  to  fourteen  days.  At  the  end  of  this  time  the  new  vascular  supply 
will  have  developed,  and  one  end  of  the  flap  is  divided,  and  the  latter 
turned  in  so  as  to  cover  the  defect.  This  method  certainly  does  over- 
come great  difficulties  with  regard  to  the  nutrition  of  the  flaps,  but  cases 
in  which  such  elaborate  measures  are  necessary  are  usually  more  success- 
fully treated  by  Thiersch's  skin-grafting. 

Occurrence  of  Sepsis  in  Open  Wounds. — Should  these  wounds  become 
septic  in  consequence  of  some  error  committed  during  the  operation  or 
the  subsequent  treatment,  the  results  as  regards  the  patient  are  not  usually 
of  a  very  serious  character,  unless  the  wound  communicates  with  a  cavity 
in  the  bone  or  with  the  interior  of  a  joint,  etc. ;  the  wound  being  widely 
open,  the  septic  material  readily  flows  away  into  the  dressing,  and  only 


TREATMENT   OF    INCISED   WOUNDS.  181 

a  small  amount  of  the  poisonous  substances  remains  to  be  absorbed. 
Nevertheless,  if  the  wound  be  at  all  large,  the  temperature  rises  at  first, 
and  a  varying  degree  of  traumatic  fever  occurs,  while  the  edges  of  the 
wound  become  swollen,  red  and  painful,  and  in  the  course  of  two  or 
three  days  its  surface  becomes  covered  with  a  layer  of  granulation  tissue. 

Treatment. — As  soon  as  it  is  thought,  from  the  rise  of  temperature 
and  other  symptoms,  that  sepsis  has  occurred,  the  dressings  should  be 
removed,  and  if  then  it  be  evident  that  the  antiseptic  treatment  has  not 
been  altogether  successful,  the  surface  of  the  wound  should  be  thoroughly 
cleansed  and  all  the  adhering  portions  of  blood-clot  removed.  In  most 
cases  where  the  symptoms  are  not  severe,  the  cyanide  dressings  may  be 
continued,  but  they  will  need  to  be  changed  daily,  and  the  surface  of 
the  wound  will  require  to  be  washed  with  a  1-2000  sublimate  solution. 
If  there  be  much  inflammation,  it  will  be  well  to  put  a  layer  of  mackintosh 
outside  the  wet  cyanide  dressings,  so  as  to  keep  them  moist,  and  then 
the  dressing  should  be  changed  night  and  morning.  Carbolic  acid  is  not 
a  good  lotion  to  apply  to  the  surface  of  these  wounds,  especially  in  the 
early  period,  because  it  seriously  injures  the  vitality  of  the  granulation 
cells,  and  thus  interferes  with  their  power  of  destroying  the  virulent 
organisms  on  the  surface.  Moreover,  granulating  wounds  treated  with 
carbolic  acid  absorb  much  more  readily  than  when  treated  in  other  ways- 

Where  the  discharges  are  very  foul,  iodoform  is  often  useful,  for, 
although  as  an  antiseptic  the  drug  is  of  very  little  value  and  is  not  at  all 
to  be  recommended  for  a  freshly  made  wound  where  the  surgeon  presumably 
takes  all  precautions  necessary  to  prevent  the  entrance  of  micro-organisms, 
it  does  become  more  or  less  of  an  antiseptic  when  applied  to  a  putrefying 
sore.  It  then  seems  to  break  up  the  toxic  products  of  the  bacteria,  and  in 
doing  so  becomes  decomposed  itself  and  free  iodine  is  liberated.  Hence,  in 
septic  wounds,  the  drug  by  destroying  the  products  of  the  bacteria  takes 
away  their  weapons  so  to  speak,  while  at  the  same  time  the  iodine  liberated 
inhibits  the  growth  of  the  bacteria,  or  may  even  actually  destroy  them. 
Whenever  iodoform  is  used,  it  should  be  disinfected  beforehand  by  immersing 
it  in  a  1-20  carbolic  acid  solution  for  several  days,  straining  it  through 
muslin,  and  then  drying  it  under  cover. 

When  in  these  septic  wounds  granulation  is  complete  and  the  febrile 
condition  has  passed  off,  it  is  well  to  substitute  mild  antiseptic  dressings, 
such  as  antiseptic  ointments,  or  the  boracic  lint  and  protective  dressing 
used  in  ulcers  (see  p.  47).  Of  ointments,  the  ung.  boracis  is  undoubtedly 
the  best ;  at  first  it  should  be  of  the  full  pharmacopceial  strength ;  but 
after  four  or  five  days,  when  healing  is  commencing,  half  or  even 
quarter  strength  should  be  substituted,  because  the  full-strength  ointment 
seems  to  be  too  irritating  for  the  young  epithelial  cells,  and  prevents  the 
cicatrization  of  the  wound.  If  the  wound  be  large,  skin-grafting  may  be 
employed  after  about  a  fortnight,  and  in  that  case  the  process  is  exactly 
the  same  as  in  grafting  an  ulcer  (see  p.  50). 


1 82  WOUNDS. 

WOUNDS   THAT   CANNOT   BE   KEPT   ASEPTIC. 

The  second  great  division  of  wounds  made  by  the  surgeon  are  those 
which  not  only  involve  the  skin,  but  communicate  with  one  of  the  mucous 
canals  or  with  a  septic  cavity  which  cannot  be  effectually  disinfected.  It 
is  impossible,  for  example,  to  exclude  bacteria  from  a  wound  in  the  mouth, 
seeing  that  they  are  everywhere  present  in  the  fluids  on  the  surface  of 
the  mucous  membrane.  The  problem,  therefore,  is  not  how  to  exclude 
bacteria  from  these  wounds,  but  how  to  minimise  their  deleterious  action. 

Wounds  of  MUCOUS  Membranes. — In  the  first  place,  it  is  important 
that,  during  the  performance  of  the  operation,  the  manipulations  should  be 
gentle,  and  pinching  or  rough  treatment  of  the  tissues  should  be  avoided ; 
in  other  words,  their  vitality  must  be  interfered  with  as  little  as  possible. 
In  wounds  involving  the  mucous  membranes,  union  by  first  intention 
should  not  be  aimed  at,  except  in  rare  cases  such  as  operations  for  cleft 
palate,  etc.  Where  union  by  first  intention  is  desired,  the  bleeding  must 
be  thoroughly  arrested,  care  must  be  taken  that  no  foreign  material  is 
left  between  the  edges  of  the  wound,  and  that  the  whole  of  the  cut  surface, 
and  not  merely  the  edge  of  the  mucous  membrane,  is  in  accurate  and 
close  apposition.  In  wounds  of  mucous  membranes  healing  by  blood- 
clot  will  not  take  place.  The  use  of  silk  for  stitches  in  these  cases  is 
out  of  the  question,  because  it  is  absorbent  and  will  retain  decomposing 
material.  The  best  material  is  either  silkworm  gut,  or,  where  a  finer  stitch 
is  wanted,  horse-hair.  No  dressing  applied  to  the  wound  is  likely  to  be 
of  any  real  service,  but  it  is  well,  instead,  to  wash  the  surface  of  the 
mucous  membrane  frequently  with  weak  antiseptic  solutions,  such  as 
Condy's  fluid  (one  or  two  grains  to  the  ounce),  or  sanitas  (about  a  tea- 
spoonful  to  the  tumbler  of  water).  The  more  irritating  antiseptics,  such 
as  carbolic  acid,  should  not  be  employed. 

Where  the  edges  of  the  wound  are  not  brought  together,  and  where, 
therefore,  healing  by  granulation  must  take  place,  it  is  of  great  importance 
to  avoid  septic  decomposition  on  the  surface  of  the  wound  during  the 
first  two  or  three  days ;  at  the  end  of  that  time,  there  is  usually  such  a 
marked  invasion  of  cells  in  the  wound,  that  bacteria  find  considerable  diffi- 
culty in  entering.  Almost  the  only  bacteria  that  are  able  to  penetrate  at 
a  later  period  than  this  are  streptococci  or  such  organisms  as  the 
diphtheritic  bacteria.  For  keeping  these  sores  aseptic  for  the  first  few  days, 
Lord  Lister  used  to  employ  a  solution  of  chloride  of  zinc,  of  a  strength  of 
forty  grains  to  the  ounce,  thoroughly  sponged  over  the  surface  of  the 
wound  after  the  bleeding  had  been  arrested.  He  regarded  it  as,  so  to 
speak,  pickling  the  surface  of  the  wound  for  a  day  or  two  after  it 
had  been  made,  and  it  is  certainly  a  fact,  that,  after  a  thorough  appli- 
cation of  chloride  of  zinc  to  a  cut  surface  exposed  to  the  elements 
of  putrefaction,  decomposition  does  not  occur  so  early  as  where  the 
wound  is  left  to  nature,  and  therefore  this  method  is  one  which 


WOUNDS   THAT   CANNOT   BE    KEPT  ASEPTIC.  183 

may  be  strongly  recommended.  It  is  especially  in  these  cases  that 
iodoform  is  of  value,  and  it  is  well,  after  having  sponged  the  cut  surface 
with  the  chloride  of  zinc  solution,  to  powder  it  with  iodoform  crystals. 
Care  must,  however,  be  taken  in  cases  of  wounds  in  the  mouth,  not  to 
be  too  lavish  in  the  use  of  iodoform,  because  otherwise  a  considerable 
quantity  is  swallowed,  and  symptoms  of  iodoform  poisoning  may  appear. 

As  soon  as  the  wound  is  granulating,  mild  antiseptic  washes  are  all 
that  is  necessary  in  most  cases,  the  best  being  weak  sanitas  (about  a  tea- 
spoonful  to  a  tumbler  of  water),  or  permanganate  of  potash  (one  or  two  grains 
to  the  ounce).  If  the  granulations  become  prominent,  the  occasional 
application  of  solid  nitrate  of  silver  or  sulphate  of  copper  will  keep  them 
down  (see  p.  58). 

In  cases  where  the  wound  involves  both  skin  and  mucous  membrane, 
as,  for  example,  in  wounds  of  the  cheek,  the  skin  wound  should  be  stitched 
up  with  interrupted  sutures  of  silkworm  gut,  but  the  wound  on  the  mucous 
surface  should  be  left  open,  and  should  be  painted  over  with  chloride 
of  zinc  solution,  and  powdered  with  iodoform.  A  piece  of  boracic  lint 
or  gauze  wet  with  a  1-2000  sublimate  solution  should  be  laid  over  the  line 
of  the  incision  in  the  skin  for  a  few  hours,  till  the  bleeding  has  quite  ceased, 
and  then  half  strength  boracic  ointment  and  boracic  lint  may  be  substituted. 
Where  there  is  a  pocket  in  the  cellular  tissue  communicating  with  the 
mucous  surface,  as,  for  example,  where  the  wound  involves  the  neck  and 
throat,  a  large  drainage  tube  must  be  inserted  at  the  lowest  point  of  the 
wound,  so  as  to  prevent  accumulation.  After  three  or  four  days,  the  tube 
should  be  taken  out,  and  replaced  by  one  of  smaller  calibre.  This  should  be 
washed  in  a  1-20  carbolic  acid  solution,  and  subsequently  in  a  1-2000 
sublimate  solution,  every  time  the  external  dressing  is  changed.  The  ointment 
should  in  these  cases  be  changed  night  and  morning.  It  is  usually  about  the 
third  week  before  the  use  of  the  drainage  tube  can  be  given  up. 

Quite  recently  an  antistreptococcic  serum  has  been  introduced  for  use 
in  cases  of  streptococcic  infection.  The  entrance  of  streptococci  is  the  most 
serious  and  most  common  form  of  infection  in  operations  on  mucous  mem- 
branes, especially  about  the  mouth,  and  this  serum  seems  likely  to  prove  of  great 
value  when  used  as  a  prophylactic  measure  before  the  operation.1  The 
object  of  the  preliminary  injection  of  this  serum  is  to  protect  the  body  for  a 
time,  if  possible,  against  streptococcic  invasion,  so  that  the  healing  of  the 
wound  is  undisturbed  by  the  action  of  these  organisms ;  20  c.cm  of  this 
serum  should  be  injected  two  days  before,  and  10  c.cm  on  the  morning  of 
the  operation.  If  there  be  not  time  for  this,  the  injection  of  20  c.cm  the 
night  before,  and  a  similar  quantity  on  the  morning  of  the  operation,  must 
suffice.  A  special  syringe,  which  can  be  disinfected  by  boiling,  must  be 
used.  The  best  place  for  the  injection  is  in  the  flanks  or  the  loins;  the 
skin  should  be  thoroughly  purified  in  the  first  place  with  strong  mixture, 
and  the  syringe  and  needles  should  be  boiled  immediately  before  use. 
1See  Practitioner,  April,  1897. 


1 84  WOUNDS. 

The  question  of  the  value  of  this  remedy  is  still  sub  judice,  and,  as  there 
are  probably  several  forms  of  pathogenic  streptococci,  it  is  well  not  to 
place  too  much  reliance  on  it  in  any  given  case.  At  the  same  time,  it 
seems  distinctly  of  value  in  certain  cases,  if  used  as  a  prophylactic. 


INCISED   WOUNDS   INFLICTED   ACCIDENTALLY. 

Another  occasion  on  which  a  wound  may  come  under  the  notice  of 
the  surgeon  is  where  it  has  not  been  made  by  him,  but  has  been  inflicted 
some  hours  before  it  comes  under  his  care.  Here,  the  problem  is  not 
so  much  to  prevent  the  entrance  of  bacteria  into  the  wound,  as  to  destroy 
any  that  may  have  already  entered.  The  degree  of  the  contamination 
of  such  a  wound  depends  on  the  part  of  the  body  injured,  and  on  the 
weapon  with  which  the  wound  has  been  inflicted. 

In  wounds  of  the  scalp  there  is  certain  to  be  very  considerable  infection 
from  hairs  or  scurf  carried  into  the  wound  at  the  time  it  is  made ;  and  as 
suppuration  in  scalp  wounds  is  often  very  serious,  both  from  the  result  of 
the  burrowing  of  pus  under  the  scalp,  and  also  from  the  proximity  of  the 
large  veins  in  the  diploe  of  the  skull  and  the  meninges,  it  is  very  important 
that  these  wounds  should  be  thoroughly  disinfected.  In  cases  also  where 
earth  or  grease  has  been  extensively  ground  into  the  wound,  great  pains 
must  be  taken  in  the  disinfection,  more  especially  where  bones  are 
injured,  as  in  compound  fractures,  wounds  of  joints,  etc.  These  will  be 
referred  to  in  their  proper  place.  Wounds  of  the  face,  or  of  parts  not 
covered  by  clothes  or  hair,  are  not  so  likely  to  be  seriously  infected  if 
the  wounds  be  incised ;  of  course,  if  they  be  contused  or  lacerated,  the 
blunt  instrument  which  inflicted  them  may  have  carried  in  a  quantity  of 
dirt,  and  here,  in  addition,  the  edges  of  the  wound  are  usually  bruised  and 
of  imperfect  vitality. 

Treatment. — Where  the  contamination  is  but  trifling,  it  may  suffice 
to  wash  out  and  sponge  the  wound  well  with  a  1-20  carbolic  acid 
solution,  but  in  the  case  of  scalp  wounds  or  those  in  which  earth  or 
dirt  is  obviously  present,  the  treatment  must  be  much  more  thorough. 
As  a  matter  of  fact,  no  attempt  should  be  made  to  obtain  healing  by  first 
intention  over  the  whole  area  of  the  wound,  so  that  the  increased  tem- 
porary irritation  of  the  tissues  by  the  strong  antiseptics  used  for  thorough 
disinfection  is  not  a  matter  of  any  consequence.  In  badly  soiled  cases, 
and  more  especially  in  compound  fractures,  it  is  best  to  give  the  patient 
an  anaesthetic,  and  then  to  sponge  the  whole  wound  out  thoroughly  with 
undiluted  carbolic  acid,  after  scrubbing  the  wound  with  a  nail-brush  and 
strong  mixture  (see  p.  161),  picking  out  dirt  or  foreign  bodies  with  forceps, 
and  clipping  off  portions  into  which  dirt  is  obviously  ground.  In  doing 
this  the  actual  margins  of  the  wound  in  the  skin  should  be  avoided,  as 
it  may  be  necessary  to  stitch  them  together  subsequently  •  all  the  deeper 


INCISED    WOUNDS    INFLICTED   ACCIDENTALLY.  185 

parts,  especially  anywhere  where  dirt  is  present,  should  be  thoroughly 
swabbed  out  with  the  acid.  When  the  wound  in  the  deeper  parts  is  larger 
than  the  opening  in  the  skin,  the  latter  must  be  freely  incised,  so  that  the 
whole  extent  of  the  wound  is  fully  exposed.  In  some  cases,  no  doubt,  where 
the  soiling  of  the  tissues  is  very  slight,  the  strong  mixture  will  suffice.  A 
good  example  of  a  wound  of  this  kind  may  be  seen  in  a  scalp  wound 
where  hairs  and  scurf  are  present  in  the  wound.  We  shall  therefore  take 
it  as  a  type,  and  describe  the  treatment  in  detail. 

Treatment  of  a  Scalp  Wound. — In  the  first  place,  the  hair  should  be 
shaved  for  at  least  two  inches  around  the  wound  in  all  directions.  When 
all  the  hair  and  dirt  have  been  removed,  the  wound  and  the  scalp  around 
are  thoroughly  cleansed  by  turpentine,  soap  and  strong  mixture  (see  p.  161). 
If  the  wound  has  been  caused  by  a  dirty  blunt  instrument,  it  is  well  after 
arresting  the  bleeding  to  swab  the  cut  surface  with  undiluted  carbolic  acid. 
In  all  these  cases  drainage  should  be  employed,  lest  asepsis  has  not  been 
obtained  in  spite  of  the  above  vigorous  measures.  A  drainage  tube  of  a  size 
varying  according  to  the  extent  of  the  wound,  and  always  of  fairly  large 
calibre,  should  be  inserted  at  one  angle,  and  should  extend  into  any  recess  or 
pocket  that  may  be  found  beneath  the  scalp.  After  the  wound  has  been 
disinfected  and  drained,  the  hair  in  the  vicinity  should  be  thoroughly 
impregnated  with  a  paste  made  by  mixing  the  double  cyanide  of  mercury 
and  zinc  with  1-20  carbolic  lotion;  this  is  rubbed  thoroughly  into  the 
hair,  which  is  thus  readily  converted  into  an  antiseptic  dressing.  If  the 
wound  be  an  incised  one,  it  may  now  be  sewn  up  by  several  silkworm 
gut  stitches;  if  it  be  a  lacerated  one,  it  is  not  necessary  to  devote  any 
great  care  to  the  approximation  of  the  edges  of  the  wound,  because  the 
probability  is  that  primary  union  will  only  be  partial  at  best;  just  enough 
stitches  should  be  employed  to  keep  the  flap  in  place.  The  usual  anti- 
septic dressings  are  then  applied  in  the  ordinary  manner  (see  p.  169). 

If  no  pain  or  other  signs  of  sepsis  manifest  themselves,  the  wound 
should  be  dressed  in  about  four  days  and  then,  if  there  be  no  suppuration, 
the  drainage  tube  may  be  left  out  and  the  wound  allowed  to  close.  If, 
however,  the  attempt  to  secure  asepsis  has  failed  (as  will  be  evidenced  by 
local  inflammation  and  general  fever),  the  dressings  must  be  changed  more 
frequently,  but  in  no  case  is  it  advisable  to  wash  out  the  wound  with  an 
antiseptic  solution,  as  is  so  often  recommended. 

WOUNDS   ALREADY   SEPTIC. 

Another  group  of  incised  wounds,  not  made  by  the  surgeon,  that  demand 
consideration  are  those  in  which  several  days  at  least  have  elapsed  between 
their  infliction  and  the  time  they  come  under  the  surgeon's  notice.  Wounds 
of  this  kind  may  be  divided  into  open  granulating  wounds,  and  those  in 
which  there  is  only  a  small  opening  at  the  surface  and  a  deep  track 
running  inwards ;  this  latter  condition  is  known  as  sinus  or  fistula. 


186  WOUNDS. 

Treatment.  —  (a)  Of  Open  Granulating  Wounds.  —  Unless  these 
wounds  are  extensive,  involve  important  structures,  or  are  situated  on  parts 
exposed  to  frequent  movement,  they  generally  heal  pretty  readily,  so  long 
as  there  is  free  exit  for  the  discharges.  The  first  essential  in  treatment 
is  to  see  that  there  is  no  retention  of  discharge  anywhere,  and  if  the  in- 
flammation be  only  slight  the  ordinary  antiseptic  cyanide  gauze  dressing 
(see  p.  169)  may  be  used  and  changed  daily;  where,  however,  the  dis- 
charge is  foul,  the  use  of  iodoform  in  addition  to  the  gauze  dressings  is 
indicated.  Where  there  is  much  inflammation  in  the  wound  and  the 
neighbouring  parts,  and  especially  if  the  wound  be  lacerated  or  contused, 
constant  irrigation  (see  p.  30)  may  be  usefully  employed.  Wherever  the 
wounds  are  in  important  situations,  such  as  the  palm  of  the  hand,  or  close 
to  and  involving  tendon  sheaths,  bones,  and  the  like,  it  is  advisable  in 
addition  to  make  an  attempt  to  obtain  thorough  and  immediate  disinfection 
of  the  part.  This  can  only  be  done  by  putting  the  patient  under  a  general 
anassthetic,  scraping  away  the  whole  of  the  granulation  tissue  from  the 
surface  of  the  wound  with  a  flushing  spoon  (see  Fig.  55),  and  sponging 
it  over  with  undiluted  carbolic  acid.  Iodoform  may  then  be  liberally 
sprinkled  over  it  and  the  ordinary  cyanide  gauze  dressings  applied.  Where 
the  wound  is  more  or  less  superficial  and  freely  exposed  to  view,  this  pro- 
cedure will  generally  secure  its  disinfection.  If  there  be  any  objection 
to  the  administration  of  an  anaesthetic,  and  if  the  wound  be  small,  a 
similar  result  may  be  obtained  by  stuffing  it  with  lint  or  gauze  soaked  in 
strong  carbolic  oil  (1-5)  and  applied  to  the  wound  without  being  wrung 
out;  the  stuffing  is  changed  night  and  morning,  and  the  surrounding  skin 
is  washed  with  a  1-20  carbolic  acid  solution.  The  strong  carbolic  oil 
does  not  actually  act  as  a  caustic,  but  it  prevents  healing,  and  therefore, 
as  soon  as  the  wound  has  assumed  a  healthy  appearance,  it  should 
be  discontinued  and  strong  boracic  ointment  used  till  healing  at  the 
edge  commences,  when  the  weaker  ointment  (^  strength)  is  substituted. 

(b)  Where  Septic  Sinuses  are  present. — Where  septic  sinuses  are 
present  within  the  area  of  operation,  as,  for  example,  in  removing  necrosed 
bone,  they  should  be  thoroughly  scraped  out  with  a  sharp  spoon,  and 
swabbed  with  undiluted  carbolic  acid,  before  the  operation  is  begun,  so 
as  to  avoid  infection  of  the  freshly  cut  surface  as  far  as  possible.  After 
the  operation  has  been  completed,  the  septic  cavity  must  be  again  scraped 
thoroughly,  and  undiluted  carbolic  acid  applied,  and  the  walls  of  the  sinuses 
should  be  cut  away  as  completely  as  possible.  In  this  way,  an  aseptic 
wound  will  be  obtained  in  a  considerable  number  of  cases;  the  edges  can 
then  be  brought  together  by  silkworm  gut  stitches,  (after  the  insertion  of 
one  or  more  large  drainage  tubes  into  the  depths  of  the  wound),  the 
ordinary  antiseptic  dressings  applied,  and  the  wound  treated  as  if  made 
through  unbroken  skin.  Should  the  attempt  to  purify  the  wound  fail,  the 
best  and  simplest  dressing  is  boracic  ointment  or  boracic  lint. 

Where,  however,  the  cavity  in  the  deeper  parts  is  large,  as  after  operations 


WOUNDS   ALREADY   SEPTIC.  187- 

for  necrosis,  it  is  best  to  stuff  the  wound  from  the  first  with  cyanide  gauze, 
and  then  to  apply  the  ordinary  gauze  dressing  outside.  Unless  this  be 
done,  the  opening  in  the  skin  is  likely  to  close  so  rapidly  that  the  dis- 
charge from  the  deeper  parts  does  not  escape  freely,  and  healing  cannot 
occur ;  besides  this,  the  irritation  of  the  gauze  leads  to  unduly  rapid  growth 
of  granulations,  which  thus  fill  up  the  wound.  Under  these  circumstances, 
the  external  dressing  should  be  changed  on  the  day  following  the  operation, 
and  subsequently  as  often  as  the  amount  of  discharge  present  may  require. 
The  stuffing  should  not,  however,  be  removed  unless  it  be  quite  loose ;  it 
should  be  gently  pulled  upon  at  each  dressing  and  any  loose  portions  cut 
away,  but  where  the  wound  remains  aseptic  it  may  be  two  or  three  weeks 
before  it  can  all  be  removed.  After  the  loose  portion  has  been  cut  off,  a 
little  fresh  gauze  should  be  laid  on  the  remaining  stuffing  so  as  to  fill  up 
the  cavity.  Should  the  wound  become  septic,  the  stuffing  comes  away 
quite  readily,  and  it  should  then  be  renewed  daily  until  the  cavity  is  almost 
entirely  filled  up.  There  is  always  great  trouble  with  the  opening  in  the 
skin,  which  constantly  tends  to  close  and  leave  a  narrow  sinus  leading  into 
a  comparatively  large  cavity.  Where  it  is  evident  that  a  long  time  must 
elapse  before  a  cavity  can  fill  up,  it  is  a  good  plan  to  cut  away  a  consider- 
able portion  of  the  skin  around  the  margin  of  the  opening  at  the  time  of 
the  operation ;  any  overhanging  portion  should  always  be  cut  away,  as  it 
would  only  become  inverted  and  delay  healing.  There  is  sometimes  a 
good  deal  of  trouble  caused  by  inversion  of  the  edges  of  the  skin  during 
the  progress  of  healing,  and  if  this  occurs  a  little  cocaine  may  be  injected 
(see  p.  121),  and  the  inverted  portion  cut  away.  When  the  granulations 
are  near  the  surface,  the  stuffing  should  be  given  up,  and  weak  boracic 
ointment  substituted. 


CHAPTER    IX. 

WOUNDS. 

PUNCTURED,  CONTUSED,  LACERATED  AND  POISONED  WOUNDS; 
BURNS,  SCALDS,  AND  FROSTBITES. 

PUNCTURED  WOUNDS. 

Characters. — A  punctured  wound  is  one  made  by  a  narrow  instrument 
so  that  its  superficial  area  is  small  in  proportion  to  its  depth ;  in  it  there  is 
generally  a  comparatively  small  opening  in  the  skin  leading  into  a  large 
irregular  wound  in  the  deeper  parts.  The  peculiar  features  of  the  punctured 
wound  are  due  to  the  elasticity  and  contractility  of  the  injured  parts ; 
the  elasticity  of  the  skin  tends  to  diminish  the  opening  in  it  and,  on  the 
other  hand,  the  contractility  of  the  muscles  beneath  tends  to  increase  the 
size  of  the  wound  in  them. 

Results. — The  results  of  punctured  wounds  depend  very  much  on 
the  particular  structures  injured.  Where  no  important  structure  is  wounded 
the  pain  is  usually  slight  and  the  haemorrhage  trifling.  If,  however,  an 
artery  be  punctured,  most  profuse  bleeding  will  result;  and,  as  we  shall 
see  when  we  come  to  speak  of  injuries  and  diseases  of  arteries,  this  is  the 
usual  way  in  which  a  false  aneurysm  is  produced.  In  punctured  wounds 
of  the  abdominal  wall,  the  instrument  may  penetrate  the  abdominal  cavity 
and  injure  one  of  the  viscera,  and  special  symptoms  will  then  occur,  the 
characters  and  treatment  of  which  will  be  considered  under  affections  of 
the  particular  organ  in  question.  Further,  if  the  instrument  which  caused 
the  puncture  pass  through  clothing,  or  if  the  puncture  be  in  a  hairy  part, 
infective  material  is  very  likely  to  be  carried  into  the  soft  parts,  and  a  septic 
wound  may  be  thereby  produced. 

Treatment. — It  is  advisable,  in  all  cases  of  punctured  wounds,  to 
enlarge  the  aperture  in  the  skin  sufficiently  to  give  thorough  access  to 
the  deeper  parts,  which  should  be  cleaned  out,  the  blood  clots  removed, 
and  the  haemorrhage  arrested.  The  wound  should  then  be  thoroughly 
washed  out  with  a  1-20  solution  of  carbolic  acid,  any  large  muscle  that 
happens  to  be  divided  should  be  stitched  together,  and  any  other  im- 


CONTUSIONS  AND   CONTUSED   WOUNDS.  189 

portant  injury  to  the  deeper  parts  (e.g.  division  of  nerves)  repaired.  When 
this  has  been  done  the  incision  which  the  surgeon  has  made,  in  order  to 
gain  proper  access  to  the  wound,  should  be  stitched  up,  and  a  small 
drainage  tube  inserted  at  the  seat  of  puncture.  As  a  matter  of  fact,  the 
puncture  would  seldom  heal  by  first  intention  if  the  edges  were  brought 
together  throughout,  and  besides  this,  one  can  never  be  certain  that  all 
the  septic  material  in  the  interior  has  been  destroyed,  and,  therefore,  it 
is  well  to  leave  an  opening  in  case  sepsis  should  occur. 


CONTUSIONS   AND   CONTUSED   WOUNDS. 

Characters. — By  a  contusion  is  understood  a  severe  bruising  of  the 
tissues  unaccompanied  by  rupture  of  the  skin.  The  parts  which  are  sub- 
jected to  the  bruising  are  more  or  less  torn  and  haemorrhage  occurs  into 
them,  so  that  if  a  contused  area  be  opened  up  it  is  found  to  be  partly 
torn  and  partly  infiltrated  with  blood  clot. 

When  the  skin  is  torn  at  the  same  time  a  contused  wound  is  produced, 
and  this  is  characterized  by  irregularity  of  the  rent  in  the  skin  and  ragged- 
ness  of  the  edges,  which  are  much  bruised  and  infiltrated  with  blood, 
the  deeper  parts  of  the  wound  and  the  parts  around  are  also  bruised 
and  bloody. 

Causes. — Contused  wounds  are  caused  by  crushes,  run-over  accidents, 
bites,  gunshot  injuries,  and  the  like.  As  a  rule  there  is  not  much  bleeding, 
the  vessels  being  torn  and  blocked;  there  is  often  great  pain,  and  the 
healing  of  the  wound  is  always  slow.  Should  it  become  septic,  there  will 
be  suppuration  and  sloughing  of  portions  of  the  contused  tissues;  if  it 
remain  aseptic,  healing  of  the  deeper  parts  takes  place  by  blood  clot,  and 
this  is  naturally  a  prolonged  process. 

Treatment. — In  the  case  of  a  simple  contusion,  the  first  object  is  to 
prevent  any  increase  in  the  haemorrhage  that  has  already  taken  place.  If 
the  contusion  be  large,  an  icebag,  or,  if  small,  an  evaporating  lotion  (see 
p.  8)  should  be  applied  for  the  first  8  or  10  hours ;  the  limb  or  the  affected 
part  should  be  kept  at  rest,  upon  a  splint  if  necessary,  in  the  elevated 
position.  As  soon  as  it  is  evident  that  no  fresh  effusion  is  going  on,  the 
indication  is  to  promote  the  absorption  of  that  already  poured  out,  and  for 
this  purpose  the  starch  and  cotton-wool  bandage  is  most  efficacious  (see 
p.  21).  After  a  few  days,  when  the  bulk  of  the  poured-out  blood  has 
been  absorbed,  the  disappearance  of  the  remainder  is  greatly  facilitated  by 
careful  massage  (see  p.  22).  When  the  damage  to  the  muscle  is  severe, 
other  measures  may  be  required,  but  this  will  be  dealt  with  again  later 
on  in  connection  with  injuries  of  muscles. 

The  treatment  of  a  contused  wound  is  directed  primarily  towards  securing 
perfect  asepsis;  the  tissues  are  so  much  damaged  by  the  injury  and  so 
much  blood  is  extravasated  into  them  that  they  are  very  liable  to  become 
the  seat  of  severe  septic  inflammation,  even  though  the  organisms  that 


190  WOUNDS. 

have  gained  access  to  the  wound  be  not  very  virulent.  As  a  first  step, 
free  access  must  be  provided  to  the  deeper  parts,  and  for  this  purpose  the 
skin  wound  must  be  enlarged,  if  necessary,  so  that  the  whole  wound  can 
be  purified.  The  particular  method  employed  for  purification  will  depend 
to  a  considerable  extent  on  the  cause  producing  the  wound.  Where  the 
skin  is  burst  rather  than  actually  torn  or  cut  by  an  instrument,  and  the 
case  is  seen  immediately  after  the  receipt  of  the  wound,  the  chances  are 
that  septic  organisms  have  not  penetrated  deep.  On  the  other  hand,  where 
the  patient  has  fallen  on  stones  or  been  run  over  by  the  wheel  of  a  cart, 
the  probability  is  that  dirt  containing  septic  organisms  has  been  firmly 
ground  into  the  tissues.  Hence,  in  the  former  case,  it  is  sufficient  to 
thoroughly  wash  out  the  wound  with  1-20  carbolic  lotion,  or,  perhaps  better, 
with  strong  mixture  (see  p.  162),  and,  if  the  tissues  be  at  all  obviously 
soiled,  to  scrub  the  skin  with  a  nail-brush  and  strong  mixture.  In  the 
second  class  of  case,  where  dirt  is  evidently  ground  into  the  tissues,  and 
more  especially  where  bone  is  injured,  it  is  best  first  of  all  to  clip  away 
any  very  dirty  tissue  and  any  tags  of  skin  and  muscle,  and  then  to  wash 
out  the  wound  with  strong  mixture,  and  finally  to  sponge  it  over  with 
undiluted  carbolic  acid.  Naturally,  in  these  bad  cases,  the  patient  should 
be  put  under  a  general  anaesthetic  while  the  wound  is  being  cleansed.  No 
stitches  whatever  should  be  employed ;  the  wound  should  be  left  freely 
open.  The  best  dressings  to  use  at  first  are  the  ordinary  cyanide  gauze 
and  salicylic  wool,  and,  should  the  wound  prove  aseptic,  a  piece  of 
protective  should  be  applied  to  its  surface  after  a  day  or  two,  in  order  to 
prevent  the  irritation  that  this  dressing  would  otherwise  cause.  After  a 
time,  if  a  considerable  raw  surface  be  left,  and  especially  if  it  be  granulating 
well,  skin-grafting  may  be  usefully  employed  (see  p.  50).  Should  suppuration 
occur  in  these  contused  wounds,  and  should  there  be  much  local  inflammation 
and  a  tendency  to  sloughing,  then  irrigation  is  the  best  treatment,  and  it 
may  be  carried  out  in  the  manner  already  described  (see  p.  30).  As  soon, 
however,  as  the  wound  becomes  covered  with  granulations,  irrigation 
should  be  discontinued,  and  either  the  gauze  dressing  employed,  or,  still 
better,  one  of  the  various  antiseptic  ointments.  The  best  of  these  is  the 
boracic  ointment,  the  full  strength  being  used  until  it  is  evident  that 
healing  has  begun  at  the  edge,  and  then  half  or  quarter  strength  ointment 
substituted  for  it  so  as  not  to  interfere  with  the  growth  of  the  young 
epithelium. 

LACERATED   WOUNDS. 

Characters. — In  lacerated  wounds  proper,  namely,  those  caused  by 
tearing,  the  bruising  of  the  deeper  tissues  is  not  nearly  so  marked  as 
in  wounds  inflicted  by  a  direct  blow  with  a  blunt  instrument.  In 
lacerated  wounds,  except  where  a  limb  is  torn  off,  the  wound  is  usually 
comparatively  superficial.  Its  characteristics  are  that  the  parts  are  much 
torn,  and  that  there  are  shreds  of  muscle  and  fascia  hanging  about  the 


LACERATED   WOUNDS. 


191 


wound.  These  structures  are  more  or  less  completely  deprived  of  blood 
supply,  and  will  slough  should  the  wound  become  septic;  in  fact,  they 
will  probably  do  so  in  any  case.  The  wound  is  usually  much  soiled, 
especially  in  machinery  accidents,  where  dirt  and  grease  are  certain  to  be 
present,  and  great  care  must  be  taken  in  disinfection. 

Causes. — These  wounds  are  inflicted  by  a  blunt  instrument,  which 
tears  the  tissues  rather  than  contuses  them ;  the  most  typical  example  of 
this  is  in  machinery  accidents,  where  a  toothed  instrument  catches  the  skin 
and  tears  it  off  for  a  considerable  distance.  Lacerated  wounds  are  always 
to  some  extent  contused  wounds,  and  a  contused  wound  may  also  be  a 
lacerated  one. 

Treatment. — The  patient  should  be  put  under  a  general  anaesthetic, 
all  tags  clipped  away,  and  the  part  thoroughly  scrubbed  with  a  nail-brush 
and  strong  mixture,  or  even  sponged  with  undiluted  carbolic  acid.  It  is 
useless  to  stitch  the  torn  skin  together;  the  most  that  should  be  done  is 
to  put  in  one  or  two  stitches  to  keep  the  flaps  somewhat  in  position.  If 
there  be  any  tension,  it  will  certainly  lead  to  sloughing  of  the  flaps,  as 
their  vitality  is  already  much  interfered  with.  The  ordinary  gauze  dressings 
should  be  used  at  first;  should  suppuration  and  much  local  disturbance  occur, 
recourse  must  be  had  to  irrigation  with  weak  Condy's  fluid  or  sanitas,  in 
the  manner  already  described  (see  p.  30).  Many  of  these  wounds  will, 
however,  heal  by  blood  clot  if  they  are  small  and  are  rendered  aseptic 
by  the  purification  described  above ;  at  any  rate,  the  greater  part  will  heal 
in  this  manner,  though  possibly  after  a  time  granulation  may  form  towards 
the  centre  of  the  wound  from  the  irritation  of  the  dressing.  When  the 
wound  is  aseptic,  there  will  be  comparatively  little  separation  of  sloughs 
either  from  the  skin  or  from  the  deeper  parts,  the  aseptic  slough,  like  a 
blood  clot,  acting  as  a  mould  in  which  new  material  is  formed. 

Where  much  skin  is  torn  off  an  extremity,  the  question  of  amputation  has 
to  be  considered.  Such  wounds,  for  instance,  as  those  where  the  whole 
skin  of  the  forearm  has  been  lost,  often  do  not  heal  at  all  on  account  of 
the  large  size  of  the  sore,  or  if  they  do,  so  much  contraction  results  that 
the  movements  of  the  joints  are  permanently  interfered  with,  the  result  in 
bad  cases  being  so  unsatisfactory  that  amputation  is  often  considered  better 
practice.  It  is  well,  however,  to  bear  in  mind  that  many  of  these  cases 
can  be  got  to  heal  by  skin-grafting,  and  a  very  useful  limb  may  result,  so 
that  the  former  rule  of  amputating  in  all  cases  where  the  loss  of  skin  from 
a  limb  is  very  extensive,  does  not  apply  so  absolutely  at  the  present  time. 
In  many  cases,  by  allowing  the  wound  to  granulate,  and  then,  after  scraping 
away  the  soft  granulating  material  which  has  already  formed,  applying 
Thiersch's  skin  grafts  (see  p.  50)  before  contraction  has  taken  place, 
extensive  wounds  can  be  induced  to  heal  without  any  marked  contraction ; 
and  there  is  always  this  to  be  said  in  favour  of  attempting  to  save  limbs 
which  at  first  do  not  promise  well,  that  amputation  can  be  performed  later 
on  should  it  be  found  that,  after  all,  the  functional  result  is  not  satisfactory. 


192  WOUNDS. 

Even  after  skin-grafting  has  been  employed,  the  great  tendency  to 
contraction  during  healing  in  these  cases  must  still  be  borne  in  mind,  and 
must  be  counteracted  by  the  careful  application  of  splints.  For  example, 
in  the  case  of  loss  of  skin  and  fascia  at  the  bend  of  the  elbow,  the  arm 
must  be  kept  carefully  extended  by  means  of  an  anterior  splint ;  where 
the  loss  is  about  the  back  of  the  hand,  it  is  well  to  keep  the  fingers 
flexed  during  the  healing  process,  the  principle  being  that,  if  contraction 
be  likely  to  occur  in  a  certain  direction,  it  is  best  counteracted  by  fixing 
the  limb  on  a  splint  bent  in  the  opposite  direction.  It  must  also  be  borne 
in  mind  that  the  tendency  of  the  scar  to  contract  does  not  by  any  means 
cease  when  healing  is  complete ;  a  young  scar  will  go  on  contracting  for 
a  considerable  time,  and  this  tendency  will  continue  for  three  or  four 
months  at  least.  Hence,  when  the  skin  over  a  joint  is  involved,  the  use 
of  a  splint  must  be  continued  for  at  least  that  length  of  time  after  the 
wound  has  healed.  It  may  not,  perhaps,  be  advisable  for  the  patient  to 
wear  the  splint  night  and  day  for  the  whole  time,  as  certain  movements 
of  the  joint  must  be  allowed  in  order  to  keep  up  its  mobility  and  the 
nutrition  of  the  muscles  about  it,  but  certainly  for  two  or  three  months 
the  splint  should  be  constantly  used,  and  then  it  may  be  left  off  during 
the  day,  and  only  applied  during  the  night  for  another  period  of  about 
three  months.  Massage  and  passive  movement  which  will  also  be  called 
for,  in  order  to  ensure  proper  movement  in  the  neighbouring  joints,  and 
to  restore  tone  to  the  muscles,  will  prove  valuable  auxiliaries  in  stretching 
the  scar. 

POISONED  WOUNDS. 

VARIETIES. — In  speaking  of  poisoned  wounds,  reference  is  usually 
made  only  to  those  following  post-mortem  examinations,  dissections,  or 
operations,  especially  upon  parts  containing  foul  pus,  etc.  We  shall  restrict 
the  term  here  to  these  conditions.  The  most  common  variety  is  the  post- 
mortem wound,  and  there  are  three  distinct  varieties  of  infection  which 
may  arise  in  this  connection. 

(a)  Lupus  Anatomicus. — This  is  the  mildest  form,  and  is  also  known 
as  anatomical  warts.  It  consists  of  warty  growths  which  appear  on  the 
fingers  of  pathologists  and  post-mortem  porters,  and  which  are  really  of  a 
tuberculous  nature.  The  soft  warts  are  often  very  rebellious  to  treatment, 
and  in  a  certain  number  of  cases  they  give  rise  to  disease  elsewhere,  for 
example,  tuberculous  glands  in  the  axilla  or  above  the  elbow,  infection  of 
neighbouring  joints  or  sheaths  of  tendons  (tuberculous  synovitis,  or  teno- 
synovitis),  lung  disease,  etc.  Hence  it  is  important  to  recognise  and 
remove  them  as  soon  as  possible. 

Treatment. — The  best  treatment  is  to  excise  the  growth,  going  wide 
of  it  in  all  directions ;  provided  that  the  wart  be  small,  the  result  is  quite 
satisfactory.  After  excision  a  skin-graft  is  applied  to  the  raw  surface,  and 
subsequent  contraction  is  thus  avoided.  Even  where  the  warty  growth  is 


POISONED    WOUNDS.  193 

extensive,  it  can  best  be  got  rid  of  in  this  way ;  should  the  tendons  be 
exposed  in  the  dissection,  loss  of  movement  need  not  be  feared  so  long 
as  the  whole  raw  surface  is  well  covered  with  skin-grafts. 

Where  the  patient  refuses  excision,  or  where  for  any  reason  the  surgeon 
does  not  wish  to  employ  it,  an  anaesthetic  should  be  administered  and 
the  warty  material  thoroughly  scraped  away;  after  the  bleeding  has  been 
completely  arrested,  the  surface  should  be  vigorously  rubbed  over  with  nitric 
acid  (not  merely  daubed  on  with  a  sponge  or  piece  of  wool  dipped  in  it), 
which  should  be  allowed  to  act  for  from  five  to  ten  minutes.  At  the  end 
of  that  time  a  strong  solution  of  carbonate  of  soda  (an  ounce  or  more  of 
carbonate  of  soda  in  a  tumbler  of  water)  is  poured  over  the  sore  to 
neutralise  the  nitric  acid;  the  effect  of  the  soda  solution  is  to  cause 
vigorous  effervescence  from  the  formation  of  carbonic  acid,  but,  as  soon 
as  the  nitric  acid  is  completely  neutralised,  this  ceases.  The  surgeon 
should,  however,  always  impress  upon  the  patient  that  by  far  the  best 
method  of  treating  this  disease  is  by  excision  and  subsequent  skin- 
grafting. 

(b)  Local  Septic  Infection. — The  other  troubles  which  arise  from  post- 
mortem wounds  are  septic  infections,  either  local  or  general.     The  results  of 
local  septic  infection  vary  in  severity  from  the  formation  of  a  small  pustule 
or  abscess,  to  an  extensive  diffuse  cellulitis  spreading  from  the  fingers  up 
the  hand  and  arm ;  the  treatment  of  these  conditions  is  that  already  described 
for  acute  abscess  or  diffuse  cellulitis  (see  Chap.  II.).     We  need  not  refer 
to  it  again  here. 

(c)  General   Septic    Infection. — The   most   serious   result   of  a  post- 
mortem  wound,   however,    is   acute   septicaemia,   and   this   is   perhaps   most 
likely    to    occur   in   wounds    inflicted    accidentally    in    making  post-mortem 
examinations   on   patients   who   have  died   of   suppurative   peritonitis ;    the 
organisms  in  the  pus  are  here  particularly  virulent.     The  disease  progresses 
with   great   rapidity,  and   the   patient  soon   passes  into  the  typhoid  state, 
and  may  die  in  from  36  to  48  hours. 

Treatment. — In  this  acute  form  of  septic  poisoning  there  is  very  little 
hope  of  a  successful  result,  as  the  disease  is  far  too  rapid  for  any  satisfactory 
intervention.  The  infection  is  most  often  due  to  streptococci,  and,  there- 
fore, at  the  present  time  we  should  be  inclined,  as  a  first  step  in  the 
treatment,  to  inject  a  quantity  of  the  antistreptococcic  serum.  In  its 
present  strength  about  20  c.c.  should  be  injected  when  the  patient  is  first 
seen,  and  this  should  be  followed  up  by  a  further  20  c.c.  in  the  course 
of  10  or  12  hours.  Apart  from  this,  the  treatment  chiefly  consists  in 
the  employment  of  stimulants,  such  as  brandy  in  ounce  doses  given  at 
intervals  of  from  two  to  four  hours  according  to  the  gravity  of  the  case, 
the  administration  of  as  much  nutritious  food  (beef  essences,  egg,  and 
milk,  etc.)  as  possible,  and  the  use  of  large  doses  of  quinine.  This  drug 
should  be  given  in  doses  of  five  grains  at  a  time,  every  three  hours,  or 
Warburg's  tincture  in  drachm  doses  at  similar  intervals  may  be  substituted 

N 


I94  WOUNDS. 

for  it  if  symptoms  of  quinism  develop.  The  wound  should  be  swabbed 
out  with  undiluted  carbolic  acid,  but  the  local  symptoms  are  usually  very 
slight  and  seldom  require  any  special  treatment.  This  acute  form  is 
extremely  fatal,  and,  in  spite  of  anything  that  may  be  done,  the  probability 
of  the  patient's  recovery  is  very  slight  indeed.  We  shall  return  to  the 
subject  again  in  dealing  with  infective  diseases  of  wounds  (see  Chap.  X.). 


BURNS   AND   SCALDS. 

Causes. — Burns  and  scalds  are  caused  by  contact  with  solids,  liquids, 
or  gases,  at  a  high  temperature.  Radiant  heat  only  causes  quite  superficial 
burns,  such  as  blisters  and  erythematous  conditions  of  the  skin.  Liquids 
below  212°  F.  cause  erythema,  but  at  or  above  that  point  they  produce 
extensive  burns,  especially  if  the  liquid  has  fallen  upon  the  clothes,  because, 
before  the  patient  has  time  to  divest  himself  of  his  clothing,  the  liquid  has 
remained  in  contact  with  the  skin  for  some  considerable  time.  Caustic 
liquids  cause  extensive  sloughs.  Red-hot  or  white-hot  solids  cause  deep 
and  limited  lesions;  fused  metals  are  extremely  rapid  in  their  action  and 
char  the  parts  completely. 

Degrees  of  Bum. — The  local  phenomena  of  burns  are,  as  originally 
proposed  by  Dupuytren,  usually  described  under  six  headings  or  degrees. 
The  first  degree  is  caused  by  the  transient  action  of  a  flame,  or  by  a  body 
below  212°  F.,  and  is  marked  by  redness  of  the  skin,  followed  by  some 
swelling  and  pain,  and  subsequently  by  desquamation.  The  second  degree 
is  caused  by  a  more  prolonged  action  of  a  flame,  or  by  boiling  water,  or 
by  solids  at  212°  F. ;  and  in  this  case  the  Malpighian  layer  of  the  skin  is 
disorganised,  and  inflammation,  as  shown  by  erythema  and  the  formation 
of  bullae,  follows.  The  third  degree  is  reached  when  one  of  the  foregoing 
causes  has  acted  for  a  longer  period,  or  where  the  burn  is  caused  by  red- 
hot  metal,  boiling  salt  water,  or  oil.  Here  there  is  destruction  of  the 
epidermis,  the  Malpighian  layer,  and  the  papillae  of  the  skin,  the  result 
being  that  there  is  erythema,  the  formation  of  bullae  and  superficial  dry 
eschars ;  the  slough  separates  in  from  about  six  to  seven  days.  The  fourth 
degree  is  where  the  whole  thickness  of  the  skin  and  part  of  the  subcutaneous 
tissue  are  destroyed ;  in  it  there  is  a  black  eschar  with  a  white  circle 
around  it,  and  then  beyond  that  a  zone  of  redness.  There  is  less  pain  in 
this  form  of  burn,  but  the  healing  is  slow.  The  fifth  degree  is  where  not 
only  the  skin  but  the  subcutaneous  tissue  and  portions  of  the  muscles  are 
completely  destroyed;  it  is  due  to  the  long-continued  action  of  flame  or 
red-hot  metals,  or  to  chemical  substances  such  as  arsenious  paste,  caustic 
potash,  etc. ;  a  dry  slough  is  formed,  and  surrounding  this  there  are  the 
various  minor  degrees  of  bums,  from  sloughing  of  part  of  the  skin  in  the 
neighbourhood  to  simple  erythema  at  a  distance.  In  this  form  of  burn, 
the  joints  are  frequently  opened,  especially  as  the  slough  separates,  and 
very  serious  results  may  consequently  ensue.  The  sixth  degree  of  burn  is 


BURNS   AND    SCALDS.  !95 

-where  all  the  tissues  of  the  limb  are  charred,  and  where  there  is  complete 
•destruction  of  the  part  subjected  to  the  heat. 

Among  the  later  effects  of  burns  is  the  occurrence  of  a  certain  amount 
of  inflammation  around  the  burnt  area,  due  directly  to  the  action  of  the 
heat;  and  besides  this,  if  the  parts  have  not  been  rendered  aseptic,  there 
may  be  septic  infection  with  severe  local  and  general  results.  Later  on 
there  is  the  separation  of  the  slough,  granulation,  and  healing. 

The  constitutional  phenomena  are  divided  into  three  stages,  which  need 
only  be  alluded  to.  The  first  stage  lasts  for  48  hours,  and  is  marked  by 
•congestion  of  the  parts  in  the  neighbourhood  of  the  burn,  and  great  pain  ; 
besides  this  there  may  be  congestions  of  the  internal  organs.  Thus,  for 
example,  when  the  burn  is  situated  over  the  thorax,  the  pleura  or  the  lungs 
may  become  congested;  when  it  is  over  the  skull,  the  meninges  may  be 
similarly  affected,  and  so  on.  During  this  stage  also  there  are  other  serious 
dangers;  for  instance,  shock,  delirium,  convulsions,  asphyxia  from  carbonic 
acid  or  carbonic  oxide  or  death  with  symptoms  of  poisoning  attributed  to 
absorption  of  the  partly  broken-up  products  of  the  burnt  tissues.  The 
second  stage  of  burns  lasts  from  the  second  to  the  sixth  or  eighth  day,  and 
is  termed  the  inflammatory  period  :  this  is  marked  by  inflammation  of  the 
part  with  sloughing  of  the  dead  tissues,  and  a  tendency  also  to  inflammation 
of  the  internal  organs ;  for  example,  a  burn  over  the  head  may  be  accom- 
panied by  inflammation  of  the  brain,  a  burn  over  the  thorax  by  inflammation 
of  the  pleura  or  the  lungs,  and  so  forth.  It  is  during  this  stage  that  the 
peculiar  phenomenon  frequently  noticed  in  burns,  namely,  inflammation 
and,  in  some  cases,  ulceration  of  the  duodenum  a  little  below  the  point  of 
entrance  of  the  bile  duct,  is  observed.  This  occurs  just  at  the  point  where 
the  contents  of  the  bile  duct  would  impinge  on  the  intestinal  mucous 
membrane,  and  is  possibly  due,  as  was  pointed  out  by  Dr.  William  Hunter, 
to  the  excretion,  with  the  bile,  of  irritating  products  resulting  from  an 
imperfect  carbonisation  of  the  tissues.  The  third  stage  begins  when  the 
slough  separates,  and  is  mainly  occupied  by  the  healing  process  :  towards 
the  end  of  the  second,  and  in  the  early  part  of  the  third  stage,  the  patient 
is  liable  to  the  various  general  septic  diseases,  which  will  be  alluded  to 
presently.  He  is  also  liable  to  local  septic  troubles  due  to  the  position  of 
the  burn;  for  example,  when  it  is  situated  over  a  cavity  such  as  a  joint 
or  the  pleura,  and  the  latter  is  opened  as  the  slough  separates,  violent  septic 
inflammation  of  the  part  (arthritis,  pleurisy,  etc.)  may  follow. 

The  Causes  of  Death  after  Burns  depend  mainly  on  the  extent,  but 
partly  also  on  the  depth  of  the  burn  and  the  region  of  the  body  affected. 
An  extensive  superficial  burn  is  much  more  dangerous  than  a  limited  but 
deep  one,  whilst  a  burn  over  the  head  or  the  thorax  is  far  more  serious 
than  a  more  extensive  one  on  an  extremity.  The  causes  of  death  after 
burns  are  (i)  shock,  (2)  collapse,  (3)  asphyxia  from  carbonic  acid  or 
carbonic  oxide,  (4)  poisoning  from  absorption  of  partially  broken-down 
•organic  products  at  the  seat  of  the  injury,  (5)  congestion  of  various  internal 


196  WOUNDS. 

organs,  (6)  inflammation  of  these  organs,  (7)  intestinal  ulceration,  (8)  various 
septic  diseases,  particularly  erysipelas,  septicaemia,  and  pyaemia,  and  (9) 
exhaustion.  In  burns  in  particular  situations  of  course  there  are  special 
dangers;  for  example,  in  scalds  of  the  throat  there  is  the  special  danger 
of  oedema  glottidis  and  death  by  suffocation. 

Treatment. — The  treatment  may  be  described  under  four  heads,  namely, 
the  treatment  of  the  first  degree,  that  of  the  second,  that  of  the  third  and 
fourth  degrees,  and  lastly,  that  of  the  last  two  degrees.  It  is  also  important 
to  describe  both  local  and  general  treatment. 

(a)  General  Treatment. — The  general  treatment  will  depend  largely 
upon  the  extent  and  result  of  the  burn.  When  a  patient  comes  under 
observation,  suffering  from  severe  shock,  the  various  measures  appropriate  for 
the  treatment  of  that  condition  (see  p.  141)  must  be  employed. 

During  the  early  stage  also,  apart  from  shock,  it  may  be  necessary  to 
counteract  carbonic  oxide  poisoning,  which  is  indicated  mainly  by  the  presence 
of  dyspnoea,  while  the  mucous  membranes  are  of  a  cherry-red  colour  and 
the  pulse  is  slow.  A  drop  of  blood  from  a  needle-puncture  shows  marked 
deviation  in  colour  from  normal  blood ;  it  is  of  the  same  bright  cherry-red  as 
the  mucous  membranes.  This  condition  is  due  to  the  carbonic  oxide  entering 
into  combination  with  the  haemoglobin,  and  preventing  the  corpuscles 
from  fulfilling  their  functions  as  carriers  of  oxygen. 

Carbonic  oxide  poisoning  must  be  treated  by  free  stimulation,  combined 
with  efforts  to  promote  the  oxygenation  of  the  blood.  In  all  cases  the 
principal  benefit  will  be  obtained  from  the  inhalation  of  oxygen,  and  this 
should  be  the  first  thing  thought  of.  Until  it  can  be  obtained,  artificial 
respiration  by  Sylvester's  method  must  be  carried  out  if  the  breathing  shows 
any  tendency  to  flag.  In  most  towns,  cylinders  of  oxygen  can  be  obtained^ 
and,  if  one  be  at  hand,  one  end  of  an  india-rubber  tube  should  be 
attached  to  the  cylinder,  and  the  other  to  a  mouthpiece  such  as  that 
of  an  ordinary  Clover's  inhaler,  or,  failing  that,  a  piece  of  brown  paper 
folded  into  a  cone ;  a  stream  of  oxygen  is  then  turned  on,  so  that  it  pours 
over  the  patient's  nose  and  mouth  in  large  quantities.  In  these  cases,  the 
oxygen  inhalation  to  do  any  good  must  be  continuous,  the  mouth  piece 
being  removed  perhaps  every  ten  minutes  or  a  quarter  of  an  hour  for  a 
minute  or  two,  and  it  must  be  gone  on  with  for  certainly  from  12  to  24 
hours,  until,  in  fact,  a  sufficient  number  of  new  blood-corpuscles  have 
been  formed  to  act  as  carriers  of  oxygen.  Where  a  cylinder  of  oxygen  is 
not  available,  and  time  permits,  the  gas  can,  of  course,  be  prepared  in  the 
usual  manner  by  heating  chlorate  of  potash  (in  quantities  of  half  an  ounce 
at  a  time)  in  a  Florence  flask  over  a  Bunsen  flame,  and  conducting  the 
oxygen  thus  obtained  through  a  suitable  tube  furnished  with  a  funnel  or 
face-piece  for  inhalation.  Transfusion  of  blood  has  been  suggested,  but  it 
seems  that  the  blood-corpuscles  thus  introduced  do  not  retain  their  vitality 
for  any  length  of  time,  and  act  only  very  temporarily,  if  at  all,  as  carriers 
of  oxygen  to  the  tissues.  As  a  stimulant  the  subcutaneous  administration 


BURNS   AND    SCALDS.  197 

of  caffeine  in  doses  of  one  grain  or  more  in  solution,  with  an  equal 
quantity  of  salicylate  of  soda,  repeated  in  three  or  four  hours,  is  of  use ; 
brandy  will  also  be  called  for. 

If,  after  the  patient  recovers  from  the  shock,  symptoms  of  internal 
congestion  or  inflammation  set  in,  the  treatment  must  be  conducted 
partly  on  the  principles  indicated  for  acute  inflammation  and  partly 
on  the  medical  lines  appropriate  to  the  organ  affected.  During  the  stages 
of  sloughing  and  convalescence,  it  is  necessary  to  support  the  patient's 
strength,  and  for  this  purpose,  the  administration  of  a  nutritious  diet  with 
plenty  of  milk,  and  the  use  of  stimulants  and  tonics,  is  of  the  greatest 
importance.  Of  the  latter,  Blaud's  iron  in  capsules  containing  ten  grains, 
three  times  a  day,  or  tinct.  ferri  perchlor,  ten  to  fifteen  minims  given 
three  times  a  day,  are  the  best.  Quinine  in  three  grain  doses  thrice  daily 
is  also  of  great  value. 

(£)  Local  Treatment.— Of  still  greater  importance  is  the  local  treat- 
ment, which  may  be  considered  in  connection  with  the  various  degrees 
of  burn.  In  the  First  Degree  the  erythema  which  occurs  from  radiant 
heat  requires  little  or  no  treatment.  The  chief  trouble  complained  of 
is  the  sensation  of  heat  and  burning  in  the  part,  and  the  use  of  some 
soothing  application,  such  as  cold  cream  or  glycerine,  which  also  acts  by 
protecting  the  surface  from  contact  with  the  air,  will  often  relieve  it :  if  not, 
lead  or  lead  and  opium  lotion  (see  p.  9)  will  be  efficacious. 

In  the  Second  Degree  where  there  are  blisters  they  should  be  punctured 
at  the  most  dependent  spot,  and  their  contents  let  out.  The  epidermis 
however  should  not  be  clipped  away,  and  the  incision  in  the  blister  should 
only  be  sufficient  to  allow  the  fluid  to  escape.  If  made  too  large  the 
epidermis  is  apt  to  peel  off,  exposing  the  papillary  layer  of  the  skin, 
causing  a  good  deal  of  pain,  and  retarding  the  healing.  Where  the  injury 
has  not  gone  beyond  the  formation  of  blisters,  it  is  hardly  necessary  to 
irritate  the  skin  by  the  use  of  antiseptic  lotions,  more  particularly  because 
the  denudation  of  the  papillary  layer  does  not  entail  any  serious  risk  of 
sepsis  ;  it  is  best  simply  to  apply  some  antiseptic  ointment  over  the  blisters 
after  they  have  been  pricked  and  their  contents  let  out.  The  most  suitable 
application  is  the  eucalyptus  ointment  of  the  Pharmacopeia,  but  weak 
boracic  ointment  (half  or  quarter  strength)  also  acts  very  well. 

The  Third  and  Fourth  Degrees. — Where  there  is  partial  or  entire  destruc- 
tion of  the  whole  thickness  of  the  skin  or  of  the  deeper  tissues,  as  is 
the  case  in  the  remaining  degrees  of  burn,  great  care  must  be  taken  to 
keep  the  parts  rigidly  aseptic,  because,  after  recovery  from  the  shock 
and  for  the  first  week  or  two  afterwards,  the  patient's  greatest  risks  are 
connected  with  sepsis.  How  best  to  secure  asepsis  is  a  question  of  consider- 
able difficulty,  for  it  must  be  remembered  that  burnt  parts  absorb  fluids 
with  extraordinary  rapidity,  and  this  is  especially  the  case  with  regard  to 
carbolic  acid.  Hence,  if  this  drug  be  freely  used  as  a  disinfectant  in  burns, 
the  gravest  symptoms  of  carbolic  poisoning,  possibly  ending  in  the  death 


198 


WOUNDS. 


of  the  patient,  may  result.  Therefore,  beyond  a  very  superficial  and  tem- 
porary application  of  the  acid  (or  the  "strong  mixture "),  the  drug  should 
not  be  used  for  the  wound,  and  the  chief  reliance  must  be  placed  on 
sublimate  solutions,  for  example  i-iooo.  If  this  be  freely  applied  and  the 
skin  at  the  same  time  soaped,  disinfection  is  very  rapidly  effected. 

In  burns,  the  heat  itself  has,  for  a  time  at  any  rate,  disinfected  *the 
part,  so  that,  should  no  subsequent  soiling  occur,  as  will  be  the  case  when 
the  patient  is  seen  quite  soon  after  the  accident,  it  is  not  necessary  to 
employ  the  disinfectant  with  the  thoroughness  required  in  ordinary  operations. 
This  more  especially  holds  good  when  the  burnt  part  has  not  been  covered 
with  clothes;  where  however  clothes  have  been  over  the  part,  the  latter 
must  have  become  soiled  in  removing  them,  and  great  care  must  then  be 
employed  in  disinfection.  As  the  patient  is  suffering  from  shock,  and  as 
the  rubbing  and  washing  necessary  for  disinfection  are  obviously  very  painful, 
additional  shock  will  be  avoided  if  a  general  anaesthetic  (preferably  ether) 
be  administered. 

Thus,  the  procedure  in  bad  cases  will  be  to  put  the  patient  under  an 
anaesthetic,  to  soap  and  wash  the  burnt  area  and  the  skin  around,  at  first 
lightly  with  strong  mixture,  and  then  more  thoroughly  with  a  i-iooo  sublimate 
solution,  which  is  subsequently  removed  by  douching,  either  with  boiled 
water  or  with  a  weak  sublimate  solution  (about  1-6000).  The  best  dressing 
is  one  of  cyanide  gauze  and  salicylic  wool,  but  the  gauze  must  be  thoroughly 
rinsed  out  in  a  very  weak  sublimate  solution  (about  1-6000  or  1-8000),  and 
not  in  carbolic  acid,  on  account  of  the  facility  with  which  the  latter  is 
absorbed.  The  dressing  should  be  left  undisturbed  for  two  or  three  days  if 
the  temperature  remain  normal  and  the  patient  be  comfortable;  indeed, 
should  there  be  no  evidence  of  sepsis  after  two  or  three  days,  the  dressings 
may  be  left  on  for  a  week  or  even  longer.  The  advantage  of  a  dressing  of 
this  kind  is  that  while  it  keeps  the  part  aseptic  it  also  allows  the  discharge 
to  dry  on  the  surface,  and  a  reference  to  the  chapter  on  Gangrene 
(Chap.  IV.)  will  show  that  one  of  the  most  important  points  in  the 
treatment  of  that  affection  is  to  promote  drying  of  the  part  When  the 
slough  begins  to  separate  (sometimes  it  does  not  do  so,  but  becomes 
organised  in  the  same  way  as  blood  clot),  and  the  parts  around  are 
granulating  well,  one  of  the  antiseptic  ointments  may  be  substituted 
for  these  cyanide  dressings.  The  best  is  eucalyptus  or  the  full  strength 
boracic  ointment.  When  the  slough  has  separated  the  wound  must  be 
treated  as  a  healing  ulcer  (see  p.  48),  and  if  of  any  size,  the  sooner  it 
is  skin-grafted  the  better  (see  p.  50). 

The  use  of  picric  acid  in  burns  has  lately  been  strongly  advocated  by  a 
number  of  writers.  It  is  claimed  for  it  that  it  allays  more  effectually  than 
the  ordinary  applications  the  intense  pain  so  often  present,  while  at  the 
same  time  it  possesses  antiseptic  properties.  It  is  generally  employed  in 
the  form  of  a  saturated  watery  solution,  which  may  either  be  painted  upon 
the  burnt  area  with  a  camel's-hair  brush,  or  may  be  applied  by  saturating 


BURNS   AND   SCALDS.  199 

a  piece  of  butter-muslin  with  it  and  laying  it  upon  the  part.  The  effect  of 
the  acid  is  to  coagulate  the  albuminous  fluid  oozing  from  the  sore,  and 
thus  to  form  a  protective  layer  over  the  exposed  nerve-ends  in  the  skin. 
The  application  should  be  made  once  or  twice  daily,  according  to  the  size 
of  the  burn  and  the  amount  of  discharge  from  it.  If  lint  or  muslin  be 
used,  it  should  be  soaked  off  by  warm  boracic  lotion.  We  have  found 
the  drug  useful  in  burns  of  the  smaller  and  more  superficial  variety  :  for 
the  more  severe  ones  we  prefer  the  method  just  described. 

It  is  especially  necessary  to  warn  the  practitioner  against  certain  appli- 
cations for  burns  which  are  commonly  recommended.  Carron  oil  for 
example  (a  mixture  of  linseed  oil  and  lime  water),  is  a  filthy  application 
and  is  responsible  for  a  great  deal  of  the  mortality  after  burns  :  the  use 
of  poultices  or  water  dressings  and  dusting  with  flour  are  equally  bad.  As 
far  as  possible,  the  wound  must  be  treated  aseptically. 

Should  the  case  come  under  observation  with  a  foul  sloughing  wound,  or 
should  the  attempt  at  disinfection  fail,  and  the  wound  become  septic, 
the  best  method  of  treatment  probably  is  the  water  bath.  If,  where  the 
trunk  is  affected,  the  burn  be  large,  very  painful,  or  accompanied  by  consti- 
tutional disturbance,  the  patient  is  placed  in  a  bath,  the  water  (at  a  tempera- 
ture of  1 00°  F.)  containing  a  small  quantity  of  an  antiseptic,  such  as  Condy's 
fluid  or  sanitas,  and  being  changed  every  three  or  four  hours.  The  patient 
should  be  taken  out  of  the  bath  at  night,  and  wet  boracic  lint  dressing 
applied ;  this  consists  of  boracic  lint  soaked  first  in  1-20  carbolic  acid, 
and  then  in  warm  saturated  boracic  solution  to  wash  away  the  carbolic  ;  it 
is  applied  wet,  and  covered  with  a  piece  of  mackintosh  (previously  dipped 
in  a  1-20  carbolic  acid  to  asepticise  it,  and  subsequently  in  boracic  lotion). 
Next  morning  the  patient  is  again  placed  in  the  water  bath,  and  kept  in 
till  evening,  and  this  method  is  continued  until  the  sloughs  have  separated 
and  the  inflammation  has  subsided.  There  is  then  no  further  necessity 
for  the  bath,  and  the  boracic  dressings,  antiseptic  ointments  or  protective 
and  boracic  lint,  applied  as  described  for  healing  ulcers  (see  p.  47), 
should  be  substituted.  Where  the  extremities  are  affected,  the  special 
baths  already  described  may  be  used  (see  p.  33). 

If  the  burn  be  of  any  size  skin-grafting  should  be  employed  (see  p.  50) 
as  soon  as  any  sloughs  have  separated  and  the  wound  has  begun  to 
granulate.  This  proceeding  is  especially  necessary  in  burns,  because  the 
sores  resulting  from  them  have  a  peculiar  tendency  to  contract.  Sores 
left  by  burns  heal  much  more  slowly  than  open  wounds  made  by  the 
knife,  probably  because  the  heat  not  only  destroys  the  vitality  of  the 
part  immediately  acted  upon,  but  also  impairs  that  of  the  tissues  around, 
so  that  in  the  early  stages  the  vital  processes  in  them  are  not  nearly  so 
active  as  usual.  Therefore,  there  is  much  more  granulation  tissue  formed, 
and  much  greater  subsequent  contraction. 

Where  the  slough  is  situated  over  a  joint  or  a  serous  cavity,  and  there 
is  reason  to  fear  that  either  may  be  opened  when  the  slough  separates, 


200  WOUNDS. 

special  care  must  be  taken  in  the  antiseptic  management  of  the  case, 
because,  should  the  part  become  septic,  there  may  be  acute  suppuration 
of  the  articular  or  the  serous  cavity,  with  all  the  evils  which  will  be  described 
when  we  come  to  speak  of  these  conditions. 

The  Fifth  and  Sixth  Degrees. — The  treatment  of  the  fifth  and  sixth 
degrees  of  burn  has  to  be  considered  essentially  in  regard  to  the 
extremities;  if  the  burn  be  situated  elsewhere,  the  patient  usually  dies  at 
once.  Should,  however,  a  burn  of  these  degrees  be  upon  the  skull  or 
parts  of  the  trunk,  and  the  patient  survive,  the  aim  of  the  treatment  must 
be  to  render  and  keep  the  part  aseptic,  to  support  the  patient's  strength, 
and  to  wait  until  the  slough  separates ;  then  if  no  vital  part  be  involved, 
the  defect  will  be  gradually  filled  up  with  granulations,  and  a  time  will  come 
when  skin-grafting  can  be  usefully  employed.  In  the  case  of  the  extremities, 
however,  when  the  tissues  down  to  and  including  the  bone  are  completely 
charred,  or  when  only  the  fifth  degree  is  reached,  and  the  tissues  are 
destroyed  over  a  large  area,  the  question  of  primary  amputation  arises. 
This  question  must  be  answered  in  the  affirmative  wherever  the  extremity 
is  seen  to  be  hopelessly  destroyed;  the  only  points  for  discussion  are 
as  to  when  and  where  the  amputation  should  be  performed.  As  a  rule 
it  is  best  to  wait  until  the  shock  has  passed  off,  for  if,  as  is  frequently 
the  case,  amputation  be  performed  before  this,  the  shock  is  very  apt  to 
be  much  increased,  and  to  bring  about  a  fatal  result.  In  the  majority  of 
cases,  if  the  part  be  roughly  disinfected  and  wrapped  up  in  an  antiseptic 
dressing,  it  is  quite  safe  to  wait  for  from  12  to  24  hours,  till  the  shock  is 
at  any  rate  partly  recovered  from,  and  then,  taking  care  to  employ  all  the 
measures  calculated  to  prevent  or  minimise  shock  (see  p.  139),  amputation 
may  be  proceeded  with.  In  determining  the  seat  of  the  amputation  it  must 
be  remembered  that  it  is  not  necessary  to  go  very  far  above  the  actually 
charred  tissue;  there  is  certainly  no  necessity  for  going  above  the  region 
of  the  erythema.  If  the  part  be  kept  aseptic  (and  of  course  special 
attention  must  be  devoted  to  the  purification  of  the  skin  in  the  region  of  the 
amputation)  this  congestion  will  subside  without  leading  to  any  trouble 
during  the  healing  of  the  stump. 


EFFECTS  OF  INTENSE  COLD. 

Local  Effects. — The  local  effects  of  cold  in  some  respects  resemble 
those  of  heat.  The  parts  chiefly  affected  are  those  most  distant  from  the 
heart,  such  as  the  toes  and  the  fingers  (especially  the  great  toe,  and  the 
little  finger),  the  nose  and  the  ears.  Moist  cold  is  more  likely  to  do 
harm  than  dry,  and  where  there  is  wind,  frost-bite  is  much  more  likely 
to  occur  than  where  the  atmosphere  is  still.  The  effect  of  cold  is  to 
cause  great  local  contraction  of  the  vessels,  so  that  the  part  becomes  at 
first  livid  and  ultimately  white.  On  the  cessation  of  the  cold,  reaction 


EFFECTS    OF    INTENSE    COLD.  2OI 

takes  place;  the  vessels  become  greatly  dilated,  while  if  the  reaction  be 
too  severe,  stasis  is  apt  to  occur,  and  may  end  in  thrombosis.  Where 
death  results  from  cold,  the  most  common  appearance  met  with  post-mortem 
is  thrombosis  of  the  vessels  of  the  internal  organs.  Various  other  local 
changes  are  described  as  the  result  of  cold,  the  most  important  being 
degeneration  or  inflammation  of  nerves ;  these  may  possibly  have  something 
to  do  with  the  peculiarly  languid  ulcerations  which  affect  parts  that  have  been 
exposed  to  severe  cold.  The  changes  probably  result  from  thrombosis  or 
rupture  of  the  nutrient  vessels  of  the  nerves. 

The  clinical  effects  of  cold  may  be  divided  into  three  degrees.  The 
first  degree  corresponds  to  the  first  degree  of  burns;  it  consists  simply  of 
erythema  of  the  part,  and  is  a  reactionary  phenomenon  :  the  second  degree 
corresponds,  at  any  rate  to  a  great  extent,  to  the  second  degree  of  burns  : 
and  the  third  degree,  or  frost-bite  proper,  may  be  taken  to  represent  the 
remaining  degrees  of  burns. 

Chilblains. — As  the  first  effect  of  cold,  therefore,  we  have  erythema. 
The  skin  becomes  of  a  wine-red  or  violet  colour,  which  disappears  on 
pressure;  the  cutaneous  circulation  is  slow  and  there  is  some  swelling  of 
the  skin  and  subcutaneous  tissues,  with  a  feeling  of  numbness  in  the  part. 
If  heat  be  applied  too  suddenly  there  is,  in  addition  to  this  feeling  of 
numbness,  much  itching  and  pricking.  This  condition  generally  disappears 
in  a  few  days ;  if,  however,  the  exposure  to  cold,  followed  subsequently  by 
the  application  of  heat,  be  repeated,  it  may  lead  to  a  more  or  less  permanent 
condition  known  as  chilblain,  which,  if  not  properly  treated,  may  become 
cracked  and  ulcerated. 

Ulcers. — The  second  degree  of  cold  leads  to  the  formation  of  bullae 
containing  clear  or  bloody  fluid,  and  these  again  are  apt  to  be  followed 
by  the  formation  of  atonic  ulcers  which  appear  quickly  and  show  little 
tendency  to  heal ;  there  is  also  smarting  in  the  part.  Where  the  con 
dition  is  yet  more  chronic  we  have  what  are  practically  ulcerating  chilblains, 
the  skin  being  swollen,  cedematous,  cracked,  and  marked  by  shallow  fissures 
which  yield  a  yellow  or  brownish  liquid,  very  prone  to  dry  up.  These 
cracks  enlarge  and  form  obstinate  ulcers. 

Frost-bite. — The  third  degree  of  cold  is  where  the  skin  and  a  varying 
amount  of  the  deeper  tissues  die ;  the  skin  becomes  livid  and  mottled  and 
numerous  large  phlyctenulge,  containing  rusty-coloured  serum,  are  formed, 
or  else  sloughing  takes  place.  If  warmth  be  applied  too  quickly,  the 
condition  results  in  severe  inflammation,  followed  by  more  or  less  extensive 
gangrene.  The  gangrene  in  these  cases  spreads  slowly,  and  there  is  a 
tendency  to  an  imperfect  and  temporary  line  of  demarcation  much  the 
same  as  in  the  senile  form ;  if  opportunity  be  afforded,  the  dead  part  dries 
up,  but  the  gangrene  is  not  typically  a  dry  one  from  the  first.  In  other  cases 
the  sloughing  is  quite  superficial,  and  the  frost-bite  is  followed  by  permanent 
mal-nutrition,  with  anaesthesia,  analgesia,  or  even  atrophy  of  the  limb,  or  the 
formation  of  perforating  ulcers. 


202  WOUNDS. 

Treatment. — (a)  Prophylactic. — The  treatment  of  the  effects  of  cold 
is  partly  prophylactic  and  partly  curative.  As  a  measure  of  prophylaxis, 
persons  who  must  necessarily  be  exposed  to  severe  cold  should  take  large 
quantities  of  fatty  food.  The  clothing  should  be  thick  and  woollen,  it 
should  not  be  tight -fitting,  and  the  feet  especially  should  be  kept  warm ; 
the  body,  particularly  the  exposed  parts,  should  be  oiled  in  order  to  prevent 
evaporation,  and  when  the  patient  is  exposed  to  intense  cold  he  should 
keep  actively  moving,  and  must  not  yield  to  the  desire  to  rest  or  sleep, 
which  is  often  very  great. 

(b)  Curative. — i.  Of  the  First  Stage. — Where  the  cold  has,  so  to  speak, 
got  hold  of  the  patient,  he  should  not  be  brought  at  once  into  a  warm 
room,  as  otherwise  the  reaction  is  likely  to  be  so  great  that  thrombosis 
of  the  vessels  occurs.  The  affected  part  should  at  first  be  rubbed  with 
snow  or  cold  water,  while,  after  a  little  time,  dry  friction  may  be  substituted, 
and  then  the  heat  very  gradually  increased.  Dry  friction  should  first  of 
all  be  practised  by  the  hand,  for  which  slightly  warmed  cloths  may  afterwards 
be  substituted,  and  then  the  patient  may  be  exposed  to  the  air  of  a  warm 
room  at  a  distance  from  the  fire.  When  this  stage  has  been  passed  and 
the  erythematous  condition  has  supervened,  the  best  applications  are 
stimulant  lotions,  such  as  camphorated  alcohol,  rubbed  into  the  part. 
The  question  of  food  is  also  important.  At  first  both  food  and  drink 
should  be  quite  cold,  and  only  gradually  should  warm  nourishment  be 
permitted. 

Treatment  of  Chilblains. — Where  chilblain  is  present  and  the  skin  is 
still  unbroken,  various  applications,  in  which  flexile  collodion  is  the  vehicle, 
are  of  great  use.  The  following  are  the  most  valuable.  Where  there  is 
great  itching,  the  irritation  can  be  much  relieved  by  the  application  of 
flexile  collodion  containing  2  per  cent,  of  cocaine.  In  painting  this  on  a 
chilblain  affecting,  say,  the  toe,  great  care  must  be  taken  not  to  surround 
the  base  of  the  toe  completely  with  it,  as  otherwise  the  contraction  which 
ensues  as  it  dries  will  exercise  a  certain  amount  of  constriction  which 
will  interfere  with  the  return  circulation.  The  collodion  should,  therefore, 
only  be  painted  on  the  main  portion  of  the  chilblain,  and  on  one  side  (in 
the  case  of  the  great  toe,  the  outer  side)  no  collodion  should  be  applied. 
Where  the  chilblains  are  very  tender,  the  use  of  turpentine  is  of  advantage, 
and  the  following  prescription  is  very  satisfactory  : 

~fy     Collodion,       -  2  oz. 

Venice  Turpentine,    -  6  drachms. 

Castor  oil,  3  drachms. 

In  this  preparation  the  turpentine  does  not  allow  the  collodion  to  dry 
completely,  and  the  stocking  is  consequently  apt  to  stick  to  the  skin ;  it 
is  well,  therefore,  to  place  a  piece  of  boracic  lint  around  the  toe  outside 
the  collodion  as  soon  as  it  has  partly  dried,  and  this  can  afterwards  be 
removed  with  warm  water.  This  application  should  be  renewed  at  least 


EFFECTS  OF  INTENSE  COLD.  203, 

once  a  day,  or  oftener  if  the  patient  has  been  walking  about.  The  use 
of  glycerine  and  belladonna  (glycer.  belladonnae,  B.P.)  over  the  inflamed 
part  is  also  of  value,  and  it  is  more  suitable  where  the  chilblain  completely 
surrounds  the  toe ;  a  piece  of  boracic  lint  is  covered  with  the  preparation 
and  wrapped  round  the  toe. 

Where  the  chilblains  are  ulcerating,  the  best  application  is  balsam  of 
Peru ;  a  piece  of  lint  soaked  in  the  balsam,  and  with  some  excess  of  it 
on  the  surface,  is  applied  over  the  sore.  In  changing  the  dressings,  the 
use  of  warm  boracic  lotion  to  bathe  the  part  is  sufficient;  the  application 
should  be  renewed  night  and  morning. 

A  patient  suffering  from  chilblains  derives  great  benefit  from  the  use 
of  cod  liver  oil  and  syrup  of  iodide  of  iron  internally,  a  teaspoonful  of 
cod  liver  oil  with  20  to  25  minims  of  syrup  of  iodide  of  iron  being  taken 
three  or  four  times  a  day.  Nourishing  diet,  with  plenty  of  fatty  food, 
should  be  given,  and  when  the  chilblains  affect  the  feet,  and  have 
ulcerated,  every  effort  should  be  made  to  induce  the  patient  to  lie  upr 
or  at  least  to  refrain  from  walking. 

2.  Of  the   Second   Stage. — In    the  second   stage   of  cold,    the    use    of 
stimulant    lotions    or    balsam    of    Peru    (see   p.    202)   is   best   in   the   first 
instance.     As   the   ulceration   in    this   case   is    usually    of  an    atonic    form, 
everything  possible  should  be  done  to  increase  the  nutrition   of  the  limb. 
Massage  applied  to  the  whole  limb  above  the  limit  of  the  sore   will  keep- 
the   circulation   active,    and   will   be   of  great   benefit ;    in   the   same    way 
electricity  applied  to  the  part  in  the  form  of  electric  baths,  or  the  Faradic 
current  applied   to   the    muscles,   and   used   in   precisely  the  same  way  as 
for   cases    of  Raynaud's  disease,    is    of  great   value;     These  methods  have 
been  described  in  detail  (see  p.  73). 

When  the  sore  begins  to  heal,  quarter  strength  boracic  ointment  may 
be  substituted  for  the  balsam  of  Peru.  The  part  should  be  elevated, 
but  it  may  not  be  necessary  to  keep  the  patient  in  bed,  rest  on  a  sofa 
often  being  sufficient;  this  point  must,  however,  be  determined  by  seeing 
how  the  ulcer  progresses.  If  it  does  not  heal,  or  if  it  shows  signs  of 
spreading  when  the  patient  is  allowed  to  remain  on  the  sofa,  rigid  con- 
finement to  bed,  with  the  foot  elevated,  must  be  enforced.  Cod  liver 
oil  should  be  administered  internally,  along  with  stimulants  and  a 
nutritious  diet. 

3.  Of    the    Third    Stage    (Frost-bite).  —  The    treatment    of    the    third 
stage,   or   that   in   which   gangrene   occurs,   remains  to  be  considered.     In 
the   first   place,    the   part   should   be   thawed    by   friction    with    snow   (see 
p.   201),  and  then  wrapped  up  in  cotton  wool.      If,  however,  the  frost-bite 
is   evidently  severe,  it  is  as  well   to  set  to  work  at  once  to  disinfect  the 
part,   scrubbing   the   skin   with   strong   mixture   and  turpentine,   shaving  it, 
cleaning  the  nails,  and  so  forth,  as  has  already  been  described  with  regard 
to  gangrene  (see  p.  64),  and  then  wrapping  up  the  limb  in  cyanide  gauze 
and  salicylic  wool.     Immediate  amputation  should  not  be  performed ;  it  is 


204  WOUNDS. 

advisable  to  wait  for  a  line  of  demarcation.  It  is  not  uncommon  to  find 
that,  after  all,  the  slough  only  involves  the  skin  and  subcutaneous  tissues, 
or  even  only  the  surface  of  the  skin,  and  by  waiting  a  little  it  may  turn 
•out  that  amputation  is  not  called  for.  In  any  case,  there  is  no  guide  to 
the  proper  place  for  amputation  till  some  sort  of  line  of  demarcation  has 
formed,  for  it  is  impossible  to  say  at  first  to  what  extent  the  tissues  have 
been  so  damaged  by  the  cold  as  to  cause  their  death.  As  soon,  however, 
as  there  is  a  clear  indication  of  the  extent  of  the  frost-bite,  there  is  no 
necessity  to  wait  any  longer,  and  amputation  may  be  at  once  proceeded 
with.  In  most  cases  of  frost-bite  of  the  foot,  a  Chopart's  or  Syme's  ampu- 
tation will  suffice:  it  is  seldom  that  the  gangrene  reaches  the  ankle.  If, 
however,  the  surgeon  wait  too  long,  the  gangrene  is  apt  to  spread  (as  is 
the  case  with  the  senile  form),  the  weak  tissues  being  unable  to  resist  the 
inflammation  associated  with  the  separation  of  the  dead  part.  On  the 
other  hand,  if  the  amputation  be  performed  antiseptically,  no  further  inflam- 
mation occurs,  and  there  is  no  gangrene  of  the  flaps.  Thus,  by  waiting 
too  long,  more  tissue  may  be  lost  than  if  the  amputation  were  performed 
as  soon  as  the  appearance  of  a  line  of  demarcation  indicates  the  extent 
of  the  original  gangrene. 

The  general  treatment  of  the  third   stage  of  frost-bite  is  the  same  as 
that  of  the  less  severe  forms  (see  p.   203). 


CHAPTER  X. 

WOUNDS. 
INFECTIVE   DISEASES   OF   WOUNDS. 

IN  the  preceding  chapters  we  have  laid  the  very  greatest  stress  on  the 
aseptic  management  of  the  wound,  but  no  consideration  of  the  subject 
would  be  complete  unless  reference  were  made  to  the  various  results 
which  may  ensue  either  when  these  precautions  have  not  been  taken,  or 
when  they  have  been  inefficiently  carried  out. 

In  connection  with  the  various  septic  diseases  that  may  attack  wounds, 
it  must  be  remembered  that,  although  we  shall  describe  such  affections  as 
septic  intoxication,  traumatic  fever,  septicaemia  and  pyaemia  as  different 
conditions  possessing  clearly  differentiated  symptoms  and  a  definite  patho- 
logy, yet  in  actual  practice  there  are  numerous  gradations  between  them, 
so  that  it  is  often  impossible  to  say  when  one  ends  and  another  begins. 
Thus  a  condition  of  septic  intoxication  very  readily  passes  into  one  of 
traumatic  fever,  which  in  its  turn  may  end  in  one  of  the  forms  of  septicaemia 
or  of  pyaemia.  Even  septicaemia  and  pyaemia,  which  are  the  two  members 
of  the  group  that  differ  most  widely,  may  both  occur  as  the  result  of  the 
septic  infection  of  the  same  wound.  Indeed,  seeing  that  in  all  probability 
the  same  organisms  may  be  concerned  in  most  of  these  affections,  it  is  not 
altogether  illogical  to  regard  the  latter  as  being  merely  a  series  of  varieties 
of  the  one  fundamental  condition  of  septic  contamination,  the  particular 
form  that  the  affection  takes  depending  upon  a  variety  of  factors,  such  as 
the  virulence  and  concentration  of  the  infective  material,  the  distribution 
of  the  organisms,  and  the  anatomical  conditions  of  the  part  affected,  etc. 

SEPTIC  INTOXICATION. 

The  organisms  which  gain  access  to  wounds  may  be  either  saprophytes, 
i.e.,  those  growing  in  dead  tissues  or  in  fluids,  but  having  no  power  of 
penetrating  into  the  living  body,  or  parasites,  i.e.,  those  which  live  and 
flourish  in  the  bodies  of  animals  whose  tissues  or  fluids  furnish  suitable 
media  for  their  development ;  the  latter  group  are  usually  capable  also  of 


206  WOUNDS. 

•saprophytic  growth.  Although  the  true  saprophytes  are  unable  to  grow 
in  the  living  tissues,  they  may  nevertheless  cause  very  serious  results  and 
may  even  bring  about  the  death  of  the  patient  whose  wounds  they  infect, 
for,  as  a  result  of  their  growth  in  organic  materials,  various  poisonous 
substances  are  produced,  which  if  absorbed  into  the  body,  may  give  rise 
to  the  condition  known  as  septic  intoxication.  Septic  intoxication  therefore 
is  an  affection  produced  not  by  parasitic  growth  in  the  body  but  by  the 
absorption  of  products  of  decomposition  formed  in  the  wound.  These 
products  are  mainly  the  result  of  the  growth  of  saprophytes,  but  they 
are  also  to  some  extent  produced  by  organisms  which  can  become  parasitic 
should  the  patient  live. 

Symptoms. — The   symptoms    of    septic    intoxication   are   due    to    the 
poison  which   is   absorbed  into   the   system,  and  the  condition    in   former 
days  was  not  recognised  as  such  and  was  often  spoken  of  as  "secondary 
shock."     The  affection  can  only  occur  in  large  wounds,  because  it  is  only 
in  them  that  sufficient  toxic  material  can  be  formed  to  provide  a  poisonous 
dose ;   for  example,  it  may  be  met  with  in  amputations  at  the  hip  joint, 
operations    upon    large    joints     such    as    the    knee,    extensive    compound 
fractures,  extensive  operations  about  the  breast  and  axilla,  many  abdominal 
operations,  psoas  abscess  and  so  forth.      The  clinical  history  is  somewhat 
as    follows.      In    the    first    place,  the    operation    being   a    severe    one,    the 
patient  suffers  more  or  less  from  collapse,  with  depression  of  temperature, 
feeble  pulse,  etc.,   and   this   is  followed,  as  the  shock   is  recovered  from, 
by   reaction    with    pyrexia.      The    temperature    usually  rises    considerably 
within    24   hours ;    then   it  falls  rapidly  and  the  patient  again  passes  into 
a   condition  not  unlike   that  of  shock.      He  becomes  semi-conscious,   the 
pulse  is   weak  and  fluttering,  and  the  temperature  low ;    if  this  condition 
persist,  he   may  die.      The   affection   is   graver   in    those   who   have   renal 
disease,   for  whereas   the   poison   is   very  rapidly   excreted   by   the   healthy 
kidneys,  the  excretion  may  not  be  sufficiently  rapid  to  save  the  patient's 
life  if  they  are  diseased.     Hence  the  old  rule,  on  which  so  much  stress 
was  laid,  was   that,  where  there  was  albumen  in   the   urine,   no  operation 
should   be   undertaken.      Nowadays,    since   we   do    not    anticipate   such    a 
catastrophe   as   septic   intoxication,  this  does   not  apply   with  such   rigour. 
Milder  conditions  of  septic   intoxication   may  also    occur,  in   which  there 
is  no  great  lowering  of  temperature ;   in  them  the  patient  rapidly  recovers. 
Treatment. — («)  Local. — When  the  above  symptoms  appear,  the  clear 
indications  are   to  wash  away  all  decomposing  materials  from  the  wound, 
so  as   to  stop  the  absorption,   and  then  to  support  the  patient's  strength 
and   to   promote   the   excretion  of  the   poison  which   has   already  entered 
the   body.      Hence,    if    the    temperature,    after   having    risen    high    during 
the  first  24  hours,  falls  rapidly  and  remains  subnormal,  while,  at  the  same 
time,    symptoms    of    shock    make    their    appearance,    the    wound    should 
at  once  be  opened  up  freely,  the  stitches  taken  out,  and  all  the  decom- 
posing  blood   clot   and    other    material    cleared   out.      It   should   then   be 


SEPTIC    INTOXICATION.  2O/ 

thoroughly  irrigated  with  a  non-irritating  lotion,  such  as  a  1-10,000  sub- 
limate solution,  or,  where  the  patient  is  in  a  very  dangerous  state, 
by  boracic  lotion,  or  sterilized  water ;  it  is  well  to  employ  these  lotions 
at  a  temperature  of  about  104°  F.,  which  acts  as  a  general  stimulant, 
and  does  not  damage  the  tissues.  The  stronger  antiseptics  such  as 
carbolic  acid  should  not  be  used  for  irrigation  because  there  is  really 
no  possibility  of  disinfecting  the  wound  by  them,  and  they  may  be 
absorbed  and  render  the  patient's  condition  still  more  serious.  The 
effect  of  using  them  is  to  cause  the  formation  of  a  layer  of  coagulated 
fibrin  on  the  surface  of  the  wound,  beneath  which  the  organisms  are 
protected  and  may  grow  again. 

After  the  wound  has  been  thoroughly  washed  out,  a  few  stitches  are 
again  inserted  and  one  or  more  large  drainage  tubes  introduced  to  provide 
free  escape  for  the  discharge.  The  cyanide  gauze  and  salicylic  wool  is 
probably  as  good  a  dressing  as  can  be  applied ;  it  should  be  changed  and 
the  wound  washed  out  again  through  the  drainage  tube  in  the  course  of  a 
few  hours.  Whether  an  anaesthetic  should  be  given  for  the  purpose  of 
opening  up  and  draining  the  wound  depends  on  the  condition  of  the 
patient.  If  he  be  in  a  very  depressed  state  it  is  well  to  avoid  it,  as  the 
procedure  does  not  involve  any  great  pain,  and  the  anaesthetic  might  still 
further  add  to  the  depression. 

Even  in  the  case  of  septic  absorption  from  the  peritoneum,  the  abdomen 
should  be  opened  and  washed  out.  In  such  cases  it  must  be  remembered 
that  the  deleterious  products  will  be  in  largest  quantity  in  Douglas'  pouch 
and  in  the  flanks,  and  the  tubes  which  are  used  to  wash  out  the  peritoneum 
should  be  especially  directed  to  these  parts.  A  useful  method  of  rapidly 
washing  out  the  peritoneal  cavity  consists  in  pouring  a  sufficient  quantity 
of  fluid  (sterilized  75  %  salt  solution  at  104°  F.)  from  a  large  jug  into  the 


FIG.  61. — KEITH'S   GLASS  DRAINAGE  TUBE.      The   flange  for  securing  the  tube  in 
position  is  seen  at  the  left-hand  end  of  the  figure. 

abdominal  cavity  while  an  assistant  holds  the  edges  of  the  abdominal  wound 
apart.  When  the  abdomen  is  full,  the  hand  may  be  introduced  among  the 
intestines  especially  into  the  flanks  and  Douglas'  pouch,  so  as  to  get  the 
fluid  thoroughly  into  contact  with  all  the  parts.  The  excess  of  fluid  is 
then  got  rid  of  by  gently  compressing  the  abdominal  walls  and  the  process 
repeated  several  times.  The  fluid  remaining  may  finally  be  taken  up  by 
sponges  on  forceps,  introduced  into  Douglas'  pouch,  after  raising  the  thorax 
slightly  so  as  to  encourage  gravitation  downwards.  Then  drainage  tubes, 
preferably  of  glass,  should  be  inserted  into  each  flank  and  into  Douglas' 
pouch.  The  best  type  of  glass  abdominal  drainage  tube  is  that  known  as 
Keith's  (see  Fig.  61).  The  flange  at  its  upper  end  is  made  to  project 


208  WOUNDS. 

beyond  the  skin,  which  is  closely  sutured  around  the  tube :  the  latter 
should  be  long  enough  to  reach  down  to  the  bottom  of  the  cavity  (e.g. 
Douglas'  pouch)  that  it  is  desired  to  drain.  If  there  be  any  likelihood 
of  the  tube  slipping  into  the  abdominal  cavity  it  may  still  further  be  secured 
in  position  by  cutting  a  small  hole  in  a  thin  sheet  of  guttapercha  (which 
must  be  scrupulously  sterilized),  stretching  it  and  slipping  it  over  the  upper 
rim  of  the  flanged  end.  A  better  plan  is  to  have  two  holes  drilled  in 
the  tube  and  to  stitch  it  to  the  edges  of  the  incision,  in  the  way  recom- 
mended for  indiarubber  tubes  (see  p.  27).  The  fluid  collected  in  the  flanks 
or  in  Douglas'  pouch  will  not  drain  away  through  these  tubes  in  the  ordinary 
way  and  some  special  means  must  be  taken  to  ensure  its  removal.  This 
may  be  done  by  inserting  down  the  tube  a  narrow  twist  of  gauze  which  by 
capillary  action  sucks  up  the  fluid  and  conveys  it  to  the  dressing.  Besides 
this,  at  each  dressing,  any  fluid  there  may  be  in  the  tube  may  be  sucked  up 
by  means  of  a  fine  catheter,  kept  rigidly  aseptic,  attached  to  a  glass  syringe. 

(b}  General  Treatment.  Stimulants  are  of  course  indicated.  Brandy 
must  be  given  by  the  mouth  or  per  rectum  if  necessary ;  in  desperate  cases 
it  may  even  be  injected  subcutaneously.  Ether  in  10  to  2o-minim  doses  may 
also  be  injected ;  the  injection  should  be  made  into  the  muscles,  for  if  it  be 
merely  introduced  beneath  the  skin,  a  slough  is  apt  to  form  afterwards. 
Strychnine  is  also  of  great  value  in  this  condition,  a  thirtieth  of  a  grain 
being  given  subcutaneously  and  repeated  hourly  for  two  or  three  doses : 
its  action  is  often  increased  by  the  addition  to  it  of  a  hundredth  of  a  grain 
of  digitaline.  Under  the  combined  influence  of  these  drugs  the  pulse  becomes 
much  steadier,  for  a  time  at  any  rate,  and  the  patient's  condition  improves. 
Carbonate  of  ammonia  in  two  or  three  grain  doses,  or  sal  volatile  in  half- 
drachm  doses,  may  be  given  hourly.  In  fact  everything  must  be  done  to 
keep  the  patient  alive  for  a  few  hours  until  the  poison  in  the  blood  has 
time  to  be  excreted. 

When  recovery  is  taking  place,  the  patient  should  be  encouraged  to 
drink  large  quantities  of  fluid  so  as  to  dilute  the  poison,  and  it  is  well  to 
use  the  "imperial  drink"  referred,  to  on  page  14,  which  is  also  a  diuretic. 
Vomiting  is  a  very  distressing  feature  in  some  cases  and,  should  it  persist, 
simple  effervescing  mixtures,  such  as  effervescing  citrate  of  caffeine  in  tea- 
spoonful  doses  will  often  check  it :  a  mixture  containing  five  minims  of 
dilute  hydrocyanic  acid  with  a  drachm  of  liquor  bismuthi  to  the  ounce  of 
water  is  also  often  useful.  When  convalescence  is  established  a  liberal  diet 
must  be  ordered  and  tonics  administered.  When  the  wound  has  granulated 
further  danger  from  this  particular  form  of  septic  absorption  disappears. 

TRAUMATIC   FEVER. 

As  long  as  the  organisms  that  have  gained  access  to  a  wound  remain 
limited  to  the  fluids  or  dead  tissues  in  it,  or  are  purely  saprophytic  in 
nature,  they  are  only  capable  of  giving  rise  to  a  condition  of  septic  intoxi- 


TRAUMATIC    FEVER.  209 

cation  pure  and  simple.  Should,  however,  any  of  the  organisms  producing 
this  septic  intoxication  be  capable  of  parasitic  growth,  and  should  they 
gain  an  entrance  into  the  living  tissues  of  the  wound,  the  condition 
known  as  traumatic  fever  arises  when  the  wound  is  of  any  size.  This 
traumatic  fever  is  due  partly  to  the  absorption  of  the  products  of  sapro- 
phytic  growth  in  the  wound,  and  partly  also  to  the  entrance  of  pyogenic 
organisms ;  it  generally  continues  until  the  establishment  of  granulation 
and  suppuration.  When  it  occurs,  the  reactionary  pyrexia  which  often 
follows  operations  performed  antiseptically,  runs  up  to  103°  or  104°  F. 
instead  of  abating,  and  then  slowly  begins  to  fall  in  an  intermittent 
manner,  till  about  the  fourth  or  fifth  day,  when  it  falls  rapidly,  the  final 
descent  coinciding  with  the  complete  establishment  of  granulation.  This 
condition  of  traumatic  fever,  unless  it  end  in  septicaemia  or  pyaemia,  does 
not  usually  prove  fatal ;  at  the  same  time  suppuration  always  occurs  in 
the  wound,  and  attention  must  be  especially  directed  to  the  local  condition. 

Treatment. — As  soon  as  traumatic  fever  sets  in,  the  wound  must 
be  dressed,  and  arrangements  made  for  efficient  drainage.  Where  no 
drainage  has  been  employed,  the  wound  should  be  thoroughly  opened  up 
and  large  tubes  inserted.  Where  one  has  been  inserted  at  the  time  of 
operation,  the  wound  should  be  washed  out  with  warm  boracic  lotion, 
with  the  object  of  getting  rid  of  decomposing  clots.  This  should  be  done 
at  the  first  dressing,  but  should  not  be  repeated  at  the  subsequent  ones  ; 
washing  out  a  wound  simply  injures  the  delicate  granulation  tissue  without 
killing  the  organisms  which,  being  of  the  ordinary  pyogenic  variety,  have 
already  penetrated  into  the  tissues.  Thus,  besides  failing  to  disinfect 
the  wound,  it  may,  by  injuring  the  granulations,  enable  the  organisms 
•to  penetrate  freely  into  the  body  and  set  up  septicaemia  or  pyaemia. 

The  antiseptic  dressings  should  be  continued,  and  changed  every  day, 
and  the  surgeon  must  simply  wait  until  he  sees  whether  the  condition  merely 
ends  in  suppuration,  or  whether  some  more  serious  complication  is  going 
to  arise.  When  the  case  ends  in  suppuration,  the  temperature  falls  about  the 
fourth  or  fifth  day,  and  the  patient  soon  recovers. 

The  diet  should  be  somewhat  restricted,  and,  unless  the  temperature 
be  high  and  the  general  condition  bad,  it  is  well  to  avoid  the  use  of 
stimulants,  or  at  any  rate  to  give  them  only  in  very  small  quantities ;  during 
the  acute  sthenic  stage  of  inflammatory  fever  they  are  not  really  called 
for.  The  patient  should  take  plenty  of  "imperial  drink"  (see  p.  14), 
so  as  to  dilute  the  blood  and  keep  the  kidneys  active ;  the  bowels  should  be 
kept  gently  open  with  such  saline  aperients  as  seidlitz  powders  or  drachm 
doses  of  sulphate  of  magnesia  or  effervescing  sulphate  of  soda. 

ACUTE   SEPTICAEMIA. 

This  condition  is  much  more  serious  than  the  one  just  described. 
Like  it,  acute  septicaemia  is  also  apparently  due  to  the  pyogenic  organisms, 


210  WOUNDS. 

but  the  exact  pathology  is  not  very  clear.  It  is  sufficient  for  our  purpose 
to  point  out  that  the  affection  is  essentially  one  of  poisoning  by  chemical 
products.  The  organisms  themselves  are  not  met  with  free  in  the  blood 
in  any  large  numbers,  and  they  probably  establish  themselves  either  in 
the  wound  or  in  some  of  the  internal  organs,  whence  they  pour  septic  products 
into  the  blood.  Although  the  condition  resembles  that  of  septic  intoxica- 
tion in  being  due  to  chemical  poisoning,  it  differs  from  it  both  by  being 
exclusively  caused  by  parasitic  organisms,  and  by  the  fact  that  these  latter 
have  gained  a  footing  either  in  the  living  tissues  of  the  wound  or  in  the 
internal  organs.  Acute  septicaemia  follows  upon  the  condition  of  traumatic 
fever  just  described  when  the  latter  does  not  end  favourably. 

Symptoms. — The  symptoms  usually  begin  before  the  traumatic  fever 
has  subsided.  The  temperature,  which  has  begun  to  fall,  rises  again  to  103°  or 
104°  F.  and  remains  high,  but  with  slight  morning  remissions  of  about 
a  degree.  Rigors  are  rare,  but  the  patient  feels  ill  and  presents  at  first 
all  the  signs  of  sthenic  inflammatory  fever;  in  bad  cases  he  soon  passes 
into  the  typhoid  state.  Vomiting  is  not  uncommon,  and  sometimes  diarrhoea 
is  present,  though  more  commonly  there  is  constipation.  The  urine  fre- 
quently contains  albumen,  the  wound  is  usually  swollen  and  painful,  and 
frequently  the  discharge  from  it  is  diminished  in  quantity  or  even  com- 
pletely arrested. 

Treatment. — The  treatment  of  acute  septicaemia  can  only  be  directed 
to  the  symptoms,  except  perhaps  in  cases  where  an  examination  of  the 
discharges  from  the  wound  shows  that  the  condition  is  dependent  on  the 
presence  of  the  streptococcus  pyogenes,  when  the  antistreptococcic  serum 
should  be  injected  in  the  manner  indicated  on  page  183.  Usually  how- 
ever, there  is  nothing  to  be  done  but  to  employ  constitutional  treatment, 
in  the  hope  that  the  tissues  may  conquer  in  the  fight  against  the  organisms. 
It  is  especially  necessary  to  support  the  patient's  strength  and  hence  a 
generous  diet  should  be  given,  and  as  soon  as  the  pulse  begins  to  fail  free 
stimulation  will  be  necessary.  If  the  temperature  remains  over  103°  F., 
tepid  sponging  or  some  of  the  other  antipyretic  measures  described  on 
p.  215  must  be  adopted.  In  addition,  large  doses  of  quinine  (five  grains 
every  three  or  four  hours)  should  be  administered  until  the  patient  shows 
signs  of  quinism,  when  the  drug  should  be  discontinued,  or  Warburg's 
tincture  in  drachm  doses  substituted.  The  bowels  and  the  kidneys  should 
also  be  kept  acting  (see  p.  209).  The  disease  is  very  fatal  indeed  ;  only  a 
small  number  of  those  attacked  recover. 

The  wound  should  always  be  opened  up  and  drained  freely,  but  there 
is  no  chance  at  this  stage  of  really  disinfecting  it  or  of  preventing  the 
entrance  of  organisms  into  the  body.  A  question  which  sometimes  arises 
where  the  wound  is  in  one  of  the  extremities  is  that  of  amputation,  and 
in  a  considerable  number  of  cases  this  has  been  done.  Unfortunately, 
however,  amputation  has  very  little  effect  on  the  progress  of  the  disease, 
for  in  most  cases  the  organisms  seem  to  be  established  in  the  internal 


CHRONIC   SEPTICAEMIA   OR    HECTIC   FEVER.  211 

organs,  and  the  only  effect  of  the  amputation  is  to  diminish  the  patient's 
vitality  and  to  hasten  the  fatal  result.  Unless  the  source  of  the  general 
condition  be  definitely  limited  to  the  wound  or  its  vicinity,  amputation  is 
worse  than  useless. 


CHRONIC   SEPTIOEMIA   OR   HECTIC   FEVER. 

The  condition  known  as  hectic  fever  which  is  not  infrequently  met 
with  is  in  reality  nothing  else  than  a  chronic  septicaemia ;  it  may  follow  on 
the  acute  form  in  a  few  rare  cases,  but  is  generally  chronic  from  the  first. 
In  it  the  temperature  has  a  distinctly  hectic  character,  being  high  in  the 
evening  (101°  or  102°  F.)  and  falling  to  about  normal  in  the  morning.  In 
acute  septicaemia  also  the  pyrexia  shows  the  same  intermittent  type,  but  there, 
notwithstanding  the  morning  fall,  the  temperature  is  always  a  febrile  one. 
The  condition  of  hectic  fever,  indicated  by  the  temperature,  the  occurrence 
of  night  sweats,  wasting,  dryness  of  the  tongue,  etc.,  usually  does  not  come 
on  till  the  chronic  septicaemic  condition  has  lasted  for  some  weeks  at 
least,  and  formerly  it  was  ascribed  to  the  loss  of  certain  constituents 
of  the  blood  resulting  from  prolonged  suppuration.  There  can  be 
no  doubt,  however,  that  it  is  due  to  the  action  of  pyogenic  organisms, 
which  apparently  do  not  grow  in  the  blood  and  the  viscera,  as  is  probably 
the  case  in  acute  septicaemia,  but  are  located  mainly  in  the  wound.  After 
hectic  fever  has  lasted  for  some  time,  a  peculiar  degeneration  of  the 
blood-vessels,  termed  waxy  degeneration  or  lardaceous  disease,  takes  place, 
and  this  chiefly  affects  the  blood-vessels  in  the  liver,  the  kidney,  and  the 
intestines ;  the  result  is  that  these  vessels  become  leaky.  Hence  the 
amount  of  urine  is  increased,  there  is  albuminuria,  colliquative  diarrhosa 
and  oedema  of  the  extremities.  The  waxy  degeneration  is  due  to  the 
direct  action  upon  the  walls  of  the  blood-vessels  of  the  poisonous  bacterial 
products  circulating  in  the  blood  :  it  is  not,  as  was  formerly  supposed, 
due  to  the  loss  of  the  purulent  fluid.  The  affection  is  most  frequently  met 
with  in  association  with  tuberculous  disease,  necrosis,  etc. 

Treatment.  —Local. — In  a  case  of  hectic  fever  the  question  of 
disinfecting  the  wound  and  getting  rid  of  the  source  of  the  disease  is 
naturally  the  first  to  arise.  From  this  point  of  view,  the  cases  may  be 
divided  into  two  large  groups:  (i)  those  in  which  the  focus  of  the  disease 
can  be  entirely  removed,  and  (2)  those  in  which  this  is  impossible. 

(i)  Where  the  focus  of  disease  can  be  entirely  removed. — These  cases 
may  further  be  subdivided  into  those  (a)  in  which  some  local  operation  is 
sufficient  to  get  rid  of  the  primary  disease,  and  (&)  those  in  which  amputa- 
tion is  necessary. 

(a)  Local  operations,  such  as  the  removal  of  a  sequestrum,  or  arthrectomy 
of  a  joint,  are  called  for  wherever  the  extent  of  the  primary  disease  and 
the  anatomical  conditions  of  the  part  are  such  as  to  offer  a  good  chance 
of  completely  removing  the  cause  of  the  mischief  and  ensuring  thorough 


212  WOUNDS. 

disinfection  of  the  tissues.  In  such  cases  the  whole  extent  of  the  wound 
should  be  opened  up,  and  left  open,  after  either  excising  the  focus  of  the 
disease  completely,  or  scraping  it  out  and  sponging  it  with  undiluted 
carbolic  acid ;  it  should  then  be  packed  well  with  cyanide  gauze  sprinkled 
with  iodoform,  extending  to  all  the  recesses  of  the  wound.  The  outside 
dressing  should  consist  of  cyanide  gauze  and  salicylic  wool,  and  both  that 
and  the  stuffing  should  be  renewed  daily. 

(£)  Amputation  is  called  for  under  two  conditions :  (a)  where  the 
primary  focus  can  only  be  removed  by  amputating  the  limb,  and  (/?} 
where  amputation  is  the  only  safe  method  of  attaining  that  end. 

(a)  Perhaps  the  most  familiar  cases  in  which  amputation  is  obviously 
the  only  means  of  eradicating  the  primary  disease  are  those  of  extensive 
disease — generally  tuberculous — of  the  knee,  ankle,  elbow,  or  wrist  joints, 
accompanied  by  widespread  suppuration  and  septic  sinuses ;  any  partial 
operation  is  quite  powerless  to  arrest  it,  and  nothing  but  an  amputation 
performed  through  healthy  parts  will  be  of  any  avail. 

(/?)  Sometimes  amputation  is  the  only  safe  method  of  treatment  even 
when  the  local  disease  is  but  small  in  extent.  Should  the  changes  con- 
sequent upon  the  occurrence  of  hectic  fever  be  so  far  advanced  that  the 
patient  is  completely  worn  out,  there  will  be  little  good  gained  by  any 
partial  operation.  Quite  apart  from  the  question  of  the  deleterious  effects 
produced  by  the  shock  and  the  loss  of  blood,  which  are  often  necessarily 
very  considerable  in  an  attempt  to  remove  the  diseased  parts  by  dissection, 
the  patient's  condition  is  such  that  he  cannot  bear  the  strain  of  a  prolonged 
period  of  healing,  and  amputation  therefore  offers  the  only  chance.  Although 
formerly  the  presence  of  waxy  degeneration  of  the  kidneys  was  supposed  to 
be  a  bar  to  amputation,  we  find  now  that  in  amputation  performed  antisep- 
tically  this  is  not  so.  On  the  contrary,  not  only  does  the  hectic  fever 
subside  after  amputation,  but  the  waxy  condition  of  the  organs  tends  to 
improve,  the  liver  diminishes  in  size,  the  albumen  becomes  less  and  may 
ultimately  disappear.  Therefore,  both  with  the  view  of  saving  the  patient's 
life  and  of  arresting  the  progress  of  the  disease,  amputation  is  clearly 
indicated. 

(2)  Where  the  local  disease  cannot  be  entirely  removed. — The  greatest 
difficulty  occurs  when  the  source  of  infection  is  on  the  trunk,  as  for 
example  in  psoas  abscess.  Here  of  course  it  is  impossible  to  remove  the 
source  of  infection  entirely,  but  nevertheless  the  only  chance  for  the 
patient  is  to  render  it  as  little  virulent  as  possible.  The  best  thing  is 
to  thoroughly  scrape  and  wash  out  the  wound  with  Barker's  flushing 
spoon  (see  Fig.  55)  and  1-6000  sublimate  solution,  and  then  to  fill  it  up 
with  iodoform  and  glycerine  emulsion  in  the  manner  recommended  for 
chronic  abscess  (see  Chap.  XIV).  Another  example  in  which  treatment 
is  very  difficult  is  tuberculous  hip-joint  disease  in  which  the  pelvis  is 
extensively  involved.  Here  probably  the  best  thing  is  to  perform  amputa- 
tion at  the  hip  joint,  which  serves  the  double  purpose  of  removing  a 


PYAEMIA. 


213 


considerable  portion  of  the  diseased  tissues,  and  at  the  same  time  allowing 
free  access  to  the  mischief  in  the  pelvis.  By  careful  removal  of  as  much  of 
this  as  possible,  followed  by  disinfection  and  free  drainage  of  the  wound 
(see  above),  the  disease  may  be  completely  arrested.  When  hectic  fever 
results  from  long-standing  empyema,  it  may  be  cured  by  bringing  about 
closure  of  the  wound  by  Estlander's  operation,  or,  failing  that,  by  main- 
taining free  drainage.  Both  these  conditions  will  be  referred  to  in  more 
•detail  in  their  proper  place. 

General.  —  As  in  all  other  exhausting  diseases,  the  general  treatment 
is  to  support  the  patient's  strength  by  nourishing  food,  fresh  air,  good 
hygienic  conditions,  etc.,  and  to  give  tonics,  such  as  iron  and  quinine,  with 
stimulants  if  necessary. 


The  gravest  of  the  infective  diseases  of  wounds  is  that  known  as  pyaemia  ; 
it  usually  comes  on  from  a  week  to  ten  days  after  an  operation  or  an 
injury.  The  traumatic  fever  has  generally  passed  off,  and  the  temperature 
has  nearly  reached  the  normal,  when  the  patient  suddenly  has  a  rigor, 
usually  a  very  severe  one,  which  lasts  perhaps  from  twenty  to  forty  minutes. 
The  temperature  immediately  rises  to  103°  or  104°  F.,  remains  at  that  point 
for  perhaps  half  an  hour  or  more,  and  then  begins  to  fall  while,  coincidently 
with  the  fall,  there  is  profuse  sweating.  The  phenomena  of  pyaemia  thus 
very  much  resemble  those  of  ague  ;  there  is  first  the  cold  stage,  then 
the  hot  one,  and  finally  the  sweating.  The  temperature  after  the  attack 
may  fall  in  a  few  hours  to  what  it  was  before  the  onset  of  the  rigor,  or 
even  to  normal,  and  for  a  day  or  two  the  patient  may  seem  fairly  well. 
Then  there  is  another  rigor,  the  same  series  of  phenomena  recurs,  and 
so  the  case  progresses,  with  constantly  recurring  rigors,  the  intervals  between 
which  steadily  diminish,  while  the  temperature  in  the  intervals  does  not 
fall  as  low  as  before.  The  patient  often  becomes  jaundiced,  and  signs 
of  abscesses  in  the  lung,  joints,  etc.,  manifest  themselves,  albuminuria 
develops,  and  death  generally  occurs  about  eight  or  ten  days  after  the 
first  onset  of  the  disease. 

Pathology.  —  Although  pyaemia  probably  is  essentially  due  to  the  same 
•organisms  as  those  that  cause  septicaemia,  it  differs  widely  from  the  latter, 
not  only  in  its  clinical  characters  but  also  in  the  pathological  changes 
met  with.  From  the  point  of  view  of  treatment,  the  pathological  con- 
•dition  in  pyaemia  is  extremely  important.  The  disease  is  undoubtedly 
due  to  the  pyogenic  organisms,  the  one  most  frequently  found  being  the 
streptococcus  pyogenes.  The  lesions  found  after  death  are  abscesses  in 
various  organs,  and  suppuration  in  connection  with  various  serous  membranes  ; 
the  abscesses  are  most  numerous  in  the  lung  in  the  majority  of  cases,  or 
in  the  liver  if  the  wound  be  in  connection  with  the  bowel.  The  pathology  of 
pyaemia  is  apparently  that,  in  the  first  place,  a  vein  in  the  neighbourhood 
of  the  wound  becomes  inflamed  and  thrombosed,  and  then  organisms 


214  WOUNDS. 

grow  in  the  thrombus,  and  gradually  cause  it  to  break  up.  Small  portions 
containing  virulent  organisms  are  carried  on  in  the  blood  stream  and  become 
impacted  in  the  lungs,  in  the  case  of  thrombosis  of  the  systemic  veins, 
or  in  the  liver  where  the  portal  veins  are  the  primary  source  of  the  mischief. 
Here  probably  the  same  process  is  repeated,  and  emboli  are  again  given 
off  and  distributed  by  the  arterial  circulation,  lodging  in  the  kidney,  the 
spleen,  the  synovial  or  the  serous  membranes,  etc.,  where  they  give  rise  to 
abscesses.  These  secondary  abscesses  may  also  be  caused  by  the  growth 
of  streptococci  floating  free  in  the  blood ;  they  form  long  chains  which 
coil  up  into  masses  which  are  unable  to  pass  through  the  smaller  vessels, 
and  in  which  they  therefore  become  impacted.  The  most  important  point 
with  respect  to  treatment,  however,  is  that  the  disease  is  generally  associated 
with  thrombosis  of  a  vein,  and  is  due  to  the  detachment  of  portions  of  clot 
from  the  blocked  vessel.  In  its  earlier  stages  at  any  rate,  the  disease  is 
essentially  a  local  one,  and  can  be  effectively  treated  by  appropriate  local 
measures. 

Treatment. — (a)  Local. — The  first  point  is  to  search  for  a  thrombosed 
vein.  In  the  case  of  the  extremities  this  will  probably  be  the  main  vein 
of  the  limb.  If  a  tender,  inflamed  and  blocked  vein  can  be  found  in 
the  neighbourhood  of  the  wound,  it  should  at  once  be  cut  down  upon, 
traced  upwards  to  a  point  where  it  is  still  patent,  a  double  ligature  put 
on  it  there,  and  the  vein  divided  between.  Where  feasible  it  is  also  advisable 
to  dissect  out  the  thrombosed  vein  and  any  of  its  communicating 
branches  which  may  be  similarly  affected.  If  this  be  done  at  an  early 
stage,  when  the  patient  has  only  had  one  or  two  rigors,  the  disease  may 
often  be  completely  arrested.  The  best  example  of  what  can  be  done  in 
the  way  of  checking  pyaemia  by  this  method  of  treatment  is  seen  in  cases 
of  disease  of  the  middle  ear  with  secondary  thrombosis  of  the  lateral  sinus. 
These  particular  cases  will  be  dealt  with  fully  under  affections  of  the  ear. 
Besides  the  removal  of  the  thrombosed  vein,  which  is  the  most  important 
part  of  the  treatment,  and  really  the  only  one  that  promises  anything 
like  a  radical  cure,  there  are  various  other  points  that  should  be  attended 
to.  In  the  first  place,  the  wound  itself  should  be  disinfected,  whether 
the  vein  has  been  removed  or  not.  It  should  be  thoroughly  opened  up, 
the  pus  washed  away,  the  whole  surface  sponged  with  undiluted  carbolic 
acid,  and  the  granulations  scraped  away.  It  is  well,  before  scraping  away 
the  granulations,  to  sponge  them  with  undiluted  carbolic  acid,  so  as  to 
get  rid  of  any  organisms  lying  upon  the  surface  which  might  be  carried 
by  the  sharp  spoon  into  the  deeper  tissues ;  after  the  granulations  have 
been  removed,  the  raw  surface  left  should  be  thoroughly  impregnated  with  the 
undiluted  acid.  The  wound  should  then  be  packed  with  cyanide  gauze 
sprinkled  with  iodoform,  or  with  iodoform  gauze,  and  the  ordinary  gauze 
and  wool  dressing  applied  outside.  The  stuffing  is  renewed  at  first  daily,  and 
then  at  longer  intervals,  if  the  case  does  well.  After  a  few  days,  when 
a  fresh  layer  of  granulations  has  sprung  up,  the  stuffing  may  be  discontinued, 


PYAEMIA.  215 

a  large  drainage  tube  placed  in  the  wound  so  as  to  make  sure  that  the 
discharge  escapes  freely,  and  a  stitch  or  two  inserted  when  the  wound 
is  large.  If  the  patient  survive,  and  external  abscesses  develop,  they 
must  be  opened  early,  and  drained  freely.  When  suppuration  occurs  in 
joints  the  latter  must  be  opened  freely  and  drained  efficiently;  this  point 
will  be  dealt  with  fully  in  discussing  the  affections  of  joints.  Further 
details  as  to  local  treatment  in  special  cases  will  be  given  in  connection  with 
such  affections  as  pyaemia  after  ear  disease,  acute  osteomyelitis,  etc. 

(b}  General. — Amongst  drugs,  the  greatest  reliance  is  placed  on  quinine. 
In  most  cases  it  is  well  to  begin  with  a  large  dose, — from  15  to  20  grains 
of  sulphate  of  quinine, — and  then  after  three  or  four  hours,  to  follow  it 
up  with  five-grain  doses  every  four  hours,  unless  the  patient  shows  signs 
of  quinism,  in  which  case  it  must  of  course  be  discontinued.  Salicylate  of  soda 
may  also  be  used, — 20  grains  every  three  hours, — watching  also  for  signs 
of  salicylate  poisoning.  The  use  of  the  sulpho-carbolates  has  been  suggested 
with  the  idea  that  carbolic  acid  would  be  liberated  in  the  blood,  and 
would  there  help  to  destroy  the  organisms ;  as  a  matter  of  fact,  however, 
the  amount  of  carbolic  acid  that  could  be  thus  liberated  would  have 
absolutely  no  effect ;  and  in  practice  the  sulpho-carbolates  have  been 
found  to  be  useless.  Antipyretic  measures  must  of  course  be  employed 
when  the  temperature  is  unusually  high,  because  after  a  rigor  the  patient 
may  actually  die  of  the  hyperpyrexia.  Of  the  antipyretic  drugs,  phena- 
cetin  is  the  safest.  It  may  be  given  in  5  or  lo-grain  doses,  repeated 
every  hour  if  necessary,  the  pulse  being  carefully  watched  meanwhile  for 
any  sign  of  depression.  Antipyrin  is  no  doubt  a  still  more  effectual  anti- 
pyretic, but  it  is  a  powerful  depressant,  and,  where  the  patient  is  weakly, 
may  produce  an  alarming  degree  of  collapse.  Sponging  the  body  with  water 
at  about  90°  F.  is  a  very  rapid  and  effectual  way  of  reducing  the  temperature  ; 
it  is  very  agreeable,  and  not  at  all  depressing.  The  patient  should  be  stripped 
and  made  to  lie  between  blankets,  and  the  sponging  should  be  done  under 
the  blanket  without  exposing  the  surface  of  the  body  to  the  cold  air ;  it 
should  be  continued  for  about  ten  or  fifteen  minutes,  and  the  skin  then 
carefully  dried  with  hot  soft  towels.  Care  must  be  taken  to  maintain  the 
temperature  of  the  water  used  for  sponging.  Sponging  should  be  repeated 
whenever  the  temperature  rises  above  102°  F. 

Stimulants  will  also  be  necessary,  but  they  should  not,  in  the  early 
stage  at  any  rate,  be  pushed  to  extremes,  not  more  than  about  six  ounces 
of  brandy  being  given  in  the  twenty-four  hours.  At  a  later  period  a  larger 
quantity  may  be  required,  and  the  more  diffusible  stimulants,  especially 
champagne,  are  the  most  useful.  Given  with  or  immediately  after  food, 
they  produce  a  temporary  stimulation  and  aid  the  process  of  digestion. 

The  diet  should  of  course  be  essentially  liquid ;  the  patient  is  unable  to 
digest  solids,  and,  if  given,  they  only  accumulate  in  the  intestines  and  upset 
the  digestive  organs.  Milk,  which  may  be  combined  with  a  few  drops  of 
saccharated  lime  water  to  prevent  curdling,  and  meat  juices,  especially 


2l6  WOUNDS. 

Bovril  and  Valentine's  meat  juice,  should  be  given.  If  possible,  about  four 
pints  of  milk  should  be  given  in  the  twenty-four  hours,  and  about  a  pint 
and  a  half  of  strong  beef  tea,  with  a  teaspoonful  of  Bovril  or  Valentine's 
meat  juice  ever)'  four  hours. 

The  so-called  "Chronic  Pyaemia." — In  some  cases  a  condition 
occurs  known  as  chronic  pyaemia,  in  which  acute  abscesses  form  all  over 
the  body.  This  affection  is  not  a  true  pyaemia,  that  is  to  say,  it  is  not 
of  emboh'c  origin ;  it  is  rather  a  condition  where  the  organisms  are  floating 
free  in  the  blood  and  attack  various  weak  spots  throughout  the  body. 

Treatment. — Any  external  abscess  will  of  course  require  to  be  opened. 
Where  the  joints  become  inflamed  they  must  be  fixed  by  a  splint,  and  if 
there  be  much  pain  they  must  be  opened  freely  and  a  drainage  tube 
inserted,  so  as  to  provide  for  the  free  escape  of  the  discharge.  The  patient 
is  usually  not  in  a  condition  to  bear  any  more  severe  procedure;  besides, 
free  drainage  of  the  joint  often  suffices  for  recovery,  leaving,  no  doubt, 
more  or  less  stiffness  behind.  Whether  the  injection  of  antistreptococcic  serum 
will  be  of  use  is  a  point  which  can  hardly  be  determined  in  the  present 
state  of  our  knowledge,  but  it  is  well  to  bear  it  in  mind,  and  as  at  any 
rate  it  does  no  harm,  recourse  may  be  had  to  it.  For  details  as  to  dose, 
method  of  injection,  etc.,  see  p.  183. 

ERYSIPELAS. 

Erysipelas  may  be  defined  as  a  febrile  disease  caused  by  a  strepto- 
coccus, and  characterised  by  a  well-defined  spreading  redness  of  the  skin. 

Symptoms. — The  disease  usually  commences  from  four  days  to  a  week 
after  the  operation  or  injury,  but  it  may  occur  as  early  as  the  first  or  the 
second  day.  There  are  usually  certain  premonitory  symptoms  preceding 
the  actual  attack,  such  as  malaise,  headache,  loss  of  appetite,  and  a  feeling 
of  tension  and  pain  about  the  wound ;  this  may  be  followed  by  a  rigor. 
In  other  cases  the  disease  may  begin  suddenly  with  a  severe  rigor,  without 
any  premonitory  symptoms.  However  the  attack  may  be  ushered  in,  it 
is  followed  by  a  rapid  rise  of  temperature  to  about  104°  F. ;  there 
is  usually  only  a  single  rigor.  Along  with  the  rise  of  temperature 
there  is  headache,  and  there  may  be  some  nausea  or  vomiting,  a  rapid 
soft  pulse,  foul  tongue,  great  thirst,  scanty  urine,  diminution  of  the  dis- 
charge from  the  wound,  and  swelling  of  the  neighbouring  lymphatic 
glands,  to  which  there  may  be  red  lines  running  from  the  wound. 
Occasionally  there  is  somewhat  furious  delirium.  In  from  ten  to  twenty- 
four  hours  after  the  rigor  a  dark  red  or  crimson  blush,  sharply  marked  off 
from  the  surrounding  parts,  appears  around  the  wound,  and  the  reddened 
portion  is  somewhat  swollen.  The  redness  increases  and  usually  spreads 
along  the  course  of  the  lymphatic  vessels,  that  is  to  say,  towards  the  trunk. 
The  margin  of  the  rash  can  be  felt  as  a  distinct  raised  ridge.  Where  the 
tissues  are  lax,  as  in  the  eyelids  or  the  scrotum,  the  swelling  may  be  very 


ERYSIPELAS. 


217 


great  and  bullae  may  form  upon  the  surface ;  bullse  may  also  appear, 
although  not  so  frequently,  when  the  trunk  or  limbs  are  affected.  During 
the  course  of  the  disease  there  is  often  albuminuria.  After  six  to  eight  days 
there  is  generally  a  rapid  fall  of  the  temperature  which  keeps  high  during 
the  acute  period.  The  constitutional  phenomena  disappear,  the  appetite 
improves,  the  redness  gradually  fades  and  usually  dies  away  by  the  middle 
of  the  second  week;  finally  desquamation  occurs.  This  desquamation  is  of 
great  importance  because  it  is  in  the  scales  of  epidermis  that  the  chief 
source  of  the  erysipelas  infection  is  to  be  found.  In  bad  cases  the  disease 
may  end  fatally  during  the  second  week,  from  pyrexia  and  general 
exhaustion. 

Varieties. — This  disease  is  fortunately  very  seldom  seen  nowadays, 
and  the  form  usually  met  with  is  the  mild  one  which  ends  in  recovery. 
Formerly  a  number  of  other  varieties  were  described,  such  as  wandering 
erysipelas,  where  a  patch  of  erysipelas  appeared  in  one  spot,  then  died 
away,  and  a  fresh  patch  appeared  elsewhere,  and  so  on,  constitutional 
symptoms  usually  showing  themselves  with  the  appearance  of  each  fresh 
patch.  The  most  serious  forms  of  erysipelas  were  described  as  phlegmonous 
and  gangrenous  erysipelas ;  these  were  cases  where,  along  with  the  symptoms 
already  described,  there  was  suppuration  in  the  subcutaneous  tissues,  which 
sometimes  took  the  form  of  an  abscess,  but  more  commonly  manifested 
itself  as  a  diffuse  cellulitis;  occasionally  the  skin  sloughed  together  with  the 
•deeper  tissues.  In  these  cases  the  patient  very  soon  passed  into  a  typhoid 
state  and  often  died. 

A  question  much  debated  at  the  present  time  is,  whether  these  gan- 
grenous and  phlegmonous  varieties  of  erysipelas  are  really  due  solely  to 
the  erysipelas  organism,  or  whether  there  is  a  mixed  infection,  the  erysipelas 
organism  growing  in  the  skin,  and  the  streptococcus  pyogenes  in  the  deeper 
structures.  The  point  is  not  at  all  settled,  the  majority  of  investigators 
inclining  to  the  opinion  that  the  streptococcus  pyogenes  and  the  erysipelas 
organism  are  essentially  one  and  the  same,  being  only  slightly  modified  in 
virulence ;  according  to  this  theory  phlegmonous  erysipelas  would  be  regarded 
as  merely  a  more  virulent  form  than  the  one  that  is  commonly  seen 
nowadays.  In  favour  of  the  theory  of  a  mixed  infection  is  the  fact  that 
there  is  frequently  diffuse  cellulitis  without  cutaneous  erysipelas  and  vice 
versa ;  besides  this  there  are  points  in  the  bacteriological  history  of  the 
organisms  which  seem  to  indicate  a  distinct  though  very  slight  difference. 

Pathology. — The  streptococcus  which  causes  the  disease  spreads  in  the 
cutaneous  lymphatic  vessels,  and  is  found  in  the  skin  immediately  beyond 
the  edge  of  the  blush  ;  the  organisms  are  always  a  little  in  advance  of  the 
visible  disease.  At  the  edge  of  the  blush  the  lymphatic  vessels  are  found 
full  not  only  of  micrococci  but  also  of  leucocytes,  while  nearer  the  centre 
of  the  redness  the  micrococci  have  disappeared  and  leucocytes  only 
are  found.  Erysipelas  is,  therefore,  looked  upon  as  one  of  the  chief 
examples  of  phagocytosis,  the  phagocytes  attacking  and  destroying  the 


2i8  WOUNDS. 

organisms  and  putting  a  stop  to  their  action.     This  view  may  possibly  help 
to  explain  the  results  of  treatment. 

Treatment. — In  the  treatment  of  erysipelas  it  is  needless  to  say  that 
prophylaxis  is  extremely  important,  and  as  erysipelas  is  never  met  with 
in  aseptic  wounds,  the  best  prophylactic  is  to  secure  the  asepsis  of  all 
wounds. 

(a)  General. — The    mild    form    usually    met   with    nowadays    generally 
subsides  spontaneously  without  any  special  treatment.     Provided  there  be 
no   internal   complication,   such  as  visceral  disease,    it  generally  suffices  to 
administer  a  saline  purgative,  such  as  a  couple  of  drachms  to  half  an  ounce 
of  sulphate   of  magnesia,   and  to  see  that  the  bowels  are  afterwards  kept 
open  daily  with  smaller  doses  (about  a  drachm)  of  the  same  drug,  given  in 
warm  water  the  first  thing  in  the   morning.     A  more  pleasant  aperient  is 
effervescing  sulphate  of  soda  in  doses  of  a  drachm,  or  an  ordinary  seidlitz 
powder.     Quinine   every  four   hours    in    doses   of  one   or   two  grains   and 
tincture  of  perchloride  of  iron  are  looked  upon  as  being  of  special  value ; 
fifteen  minims  of  the  tincture  of  perchloride  of  iron  may  be  administered 
in  water  every  three  hours.     The  diet  should  be  fluid,  and  should  consist 
of  milk,  beef  tea,  or  strong  soups  given  in  fairly  large  quantity. 

(b)  Local. — Various  forms  of  local  treatment  have  been  employed,  and 
in  the  more  severe  forms  of  erysipelas  it  is  important  to  make  the  most 
strenuous  efforts  to  check  the  local  progress  of  the  disease.     In  former  days 
a   very   favourite   plan   was   to   draw   a   line   on  the  skin  around  and  just 
beyond  the  area  of  the  redness  with  solid  nitrate  of  silver,  or  to  paint  on 
liniment  of  iodine  in  a  similar  manner,  and,  as  a  matter  of  experience,  it 
was  found  that  in  a  certain  number  of  cases  the  erysipelas  stopped  at  this 
line  and  seemed  unable  to  cross  it.     At  first  sight  this  treatment  does  not 
seem  very  rational,  but  if  we  bear  in  mind  what  has  just  been  said  as  to 
the  relation  of  erysipelas  to  phagocytosis  the  treatment  becomes  explicable 
and  logical.     If  the  skin  be  irritated  with  nitrate  of  silver  or  strong  iodine 
there   will   naturally  be  increased   leucocytosis  in  the  part,   and  if  this  be 
done  a  day  or  two  before  the  erysipelas  organisms  reach  the  area  to  which 
the  irritant  has  been  applied,  they  will  find  the  tissues  and  vessels  blocked 
with  large  numbers  of  leucocytes,  and  the  phagocytic  action  of  the  latter 
may  suffice  to  prevent  their  further  spread.     Hence  it  seems  probable  that 
one  reason  why  this  method  did  not  uniformly  succeed  is  that  the  application 
was  not  always  made  sufficiently  early  or  far  enough  away  from  the  spreading 
margin  to  permit  a  sufficient  accumulation  of  leucocytes  to  occur  in  the  part 
before  the  organisms  reached  it.      This  is  not  a  method  of  treatment  that 
we  are  disposed  to  reject,  provided  that  care  be  taken  to  apply  the  irritant 
very  thoroughly  at  some  considerable  distance  from  the  edge  of  the  redness ; 
in  fact,  the  method  of  treatment  which  at  the  present  time  seems  to  promise 
best,  namely  Kraske's  method,  probably  acts  on  this  principle. 

KraskJs   Method  consists   in    making   numerous   small   scarifications  in 
the  skin  at  some  distance  beyond  the   spreading   edge   of  the   erysipelas, 


ERYSIPELAS.  219 

just  deeply  enough  to  cause  the  vessels  to  bleed.  These  scarifications 
should  be  very  numerous,  and  are  made  to  cross  each  other  and  to  sur- 
round the  whole  area  of  the  redness,  at  a  distance  of  about  2  inches  from 
its  edge  (see  Fig.  62) ;  after  the  capillary  oozing  has  ceased  the  blood  is 
wiped  away  and  the  affected  area  is  either  soaked  with  a  1-20  carbolic  acid 
solution  or  is  sprayed  with  it  for  about  an  hour.  After  the  scarification, 
and  the  spraying,  compresses  of  gauze  soaked  in  1-40  carbolic  acid 
solution  should  be  applied  over  the  scarified  surface.  The  result  is  that, 
partly  as  the  result  of  the  scarifications  and  partly  as  the  result  of  the 
carbolic  acid,  very  considerable  irritation  is  produced  all  round  the 
erysipelatous  area,  and,  as  suggested  above,  when  the  organisms  reach 
the  irritated  part  they  are  met  by  a  barrier  of  cells.  Certainly  experience 
seems  to  show  that  Kraske's  method  is  by  far  the  most  effectual  plan  of 


FIG.  62. — KRASKE'S  METHOD  OF  TREATMENT  FOR  ERYSIPELAS.  The  ring  of 
scarifications  should  be  made,  as  depicted  above,  well  clear  of  the  margin  of  the  rash. 
It  is  as  well  to  allow  an  interval  of  quite  two  inches. 

treating  erysipelas,  so  long  as  the  affection  is  a  true  cutaneous  oner 
and  not  an  inflammation  of  the  subcutaneous  tissues  as  well.  It  should 
however  only  be  used  in  severe  cases :  it  is  painful,  and  necessitates  the 
use  of  an  anaesthetic  during  the  scarification. 

There  are  many  applications  to  the  actual  erysipelatous  part  advocated 
by  various  authorities ;  some  surgeons  state  that  they  have  derived  benefit 
by  spraying  it  freely  with  carbolic  acid,  which  is  done  upon  the  presumption 
that  the  acid  is  absorbed  and,  passing  into  the  lymphatic  vessels,  directly 
affects  the  organisms ;  probably  this  idea  has  not  any  very  good  foundation 
in  fact.  In  most  cases  applications  calculated  to  relieve  the  local  discomfort 
are  sufficient.  Where  there  is  not  much  heat  or  pain,  all  that  is  necessary 
is  to  wrap  the  part  up  in  salicylic  wool.  Where  there  are  both  pain  and 
swelling,  the  use  of  lead  lotion  or  lead  and  opium  lotion  (see  p.  9)  is 
to  be  recommended,  lint  kept  constantly  moist  with  the  lotion  being  placed 
over  the  affected  area.  During  desquamation  it  is  well  to  keep  the  part 
anointed  with  some  antiseptic  ointment,  such  as  the  ung.  eucalypti.  This- 
both  relieves  the  troublesome  itching  often  complained  of,  and  lessens- 
the  chance  of  dissemination  of  the  infective  epidermic  scales. 


220  WOUNDS. 

Treatment  of  Phlegmonous  cases. — Where  the  case  is  one  of  the 
so-called  phlegmonous  or  gangrenous  erysipelas,  the  treatment  must  be 
practically  that  of  diffuse  cellulitis  (see  p.  29).  Free  incisions  should  be 
made  into  the  part  in  all  directions  so  as  to  allow  the  escape  of  the 
discharge,  and  then  constant  irrigation  carried  out  in  the  manner  already 
described  (see  p.  30). 

Antistreptococcic  Serum. — The  advisability  of  using  the  antistreptococcic 
serum  in  this  affection  must  also  be  borne  in  mind.  This  is  only  on  its 
trial  and  so  far  the  results  are  not  very  encouraging.  At  the  same  time, 
as  it  does  not  seem  to  do  any  harm,  we  are  inclined,  at  any  rate  until 
some  more  definite  conclusion  is  arrived  at  as  to  its  use,  to  recommend 
that  any  of  the  forms  of  treatment  mentioned  above  should  be  accompanied 
by  the  injection  under  the  skin  of  the  abdomen  of  a  full  dose  of  the 
anti-streptococcic  serum.  As  at  present  supplied  by  the  Jenner  Institute 
of  Preventive  Medicine,  a  full  dose  is  about  20  c.c.,  of  the  serum ;  a 
dose  of  half  that  quantity  should  be  repeated  in  twelve  hours,  while 
a  third  dose  may  be  given  twelve  hours  later  (see  also  p.  183). 

TETANUS. 

Definition. — Tetanus  may  be  defined  as  an  infective  disease  of  wounds 
due  to  a  special  bacillus  and  characterised  by  painful  tonic  contractions 
of  the  muscles  with  convulsive  exacerbations :  it  commences  in  the 
muscles  of  the  jaw  and  neck,  and  spreads  to  all  the  voluntary  muscles  of 
the  body. 

Symptoms. — The  affection  usually  begins  between  the  fifth  and  fifteenth 
day  after  the  infliction  of  the  wound,  and,  preceding  the  establishment  of  the 
disease,  there  are  often  prodromata,  such  as  a  feeling  of  malaise,  a  tendency 
to  yawn,  headache,  fear  on  the  part  of  the  patient  that  he  will  not  get  better, 
and  neuralgic  pains  in  the  wound  radiating  along  the  nerves  and  accompanied 
by  local  spasms  or  cramps. 

In  a  day  or  so  after  the  appearance  of  these  premonitory  symptoms 
the  typical  symptoms  of  tetanus  set  in :  the  muscles  of  mastication  are 
generally  the  first  to  be  affected  and  this  produces  the  condition  known  as 
trismus.  The  masticators  contract  and  more  or  less  fix  the  jaw,  and  on  any 
attempt  to  open  the  mouth  to  eat  or  drink,  convulsive  contractions  of  these 
muscles  occur.  The  spasm  next  attacks  the  muscles  of  the  neck,  resulting 
in  the  fixation  of  the  head,  and  about  the  same  time  the  muscles  of  expression 
also  become  affected,  giving  rise  to  the  risus  sardonicus.  In  this  condition 
the  angles  of  the  mouth  are  drawn  out,  the  alae  of  the  nose  elevated,  the 
eyes  widely  opened,  and  the  forehead  wrinkled.  The  next  set  of 
muscles  affected  is  generally  the  pharyngeal  group,  leading  to  spasmodic 
dysphagia.  Soon  the  voluntary  muscles  elsewhere  are  attacked,  generally 
in  groups,  those  next  affected  being  usually  the  sacro-lumbar  muscles  and 
those  of  the  lower  extremities,  leading  to  opisthotonos ;  then  the  muscles 


TETANUS.  221 

of  the  upper  extremity,  those  of  the  abdomen,  and,  fortunately  last  of  all, 
the  muscles  of  respiration.  The  great  feature  of  this  disease  is  that  the 
muscular  spasm  seldom  relaxes  altogether,  while  the  least  movement  or 
disturbance  of  the  patient  is  very  apt  to  set  up  clonic  contractions, — the  well- 
known  tetanic  spasms.  The  pulse  is  generally  pretty  rapid  during  the  course 
of  the  disease,  varying  from  100  to  140.  The  temperature  may  be  only 
slightly  raised  but  usually  it  is  up  to  104°  F.,  being  naturally  highest  during 
the  convulsions.  Where  the  temperature  goes  higher  than  104°  or  105° 
the  condition  is  generally  very  grave  and,  if  the  pyrexia  be  not  reduced, 
the  patient  often  dies  of  it.  The  respirations  are  normal  but  increase  in 
frequency  during  the  attack ;  the  patient  cannot  swallow,  the  saliva  runs 
out  of  the  mouth,  there  is  diminution  in  the  amount  of  the  urine,  but  no 
albuminuria,  and  there  is  profuse  sweating  after  the  convulsions. 

Varieties. — Tetanus  may  be  either  acute  or  chronic.  The  acute  form 
accompanied  by  high  temperature  usually  ends  fatally  in  four  days,  and 
of  those  affected  with  this  form  only  about  i  %  recover  under  ordinary 
treatment.  In  the  more  common  chronic  variety  the  convulsions  are  less 
frequent,  and  not  so  general,  but  this  form  may  become  acute  and  death 
then  rapidly  takes  place ;  about  20  %  of  the  patients  recover. 

Causes. — Tetanus  most  commonly  occurs  after  wounds  of  the  extremities. 
It  is  due  to  a  bacillus  which  is  anaerobic  and  spore-bearing,  and  which  is 
commonly  found  in  garden  earth,  in  horse-dung  and  generally  in  places 
soiled  with  the  latter.  The  reason  why  it  occurs  especially  after  wounds 
in  the  extremities  is  that  they  are  more  likely  to  be  soiled;  although 
lacerated  wounds  are  those  most  frequently  associated  with  tetanus,  it  may 
follow  a  very  slight  scratch.  It  is  not  the  amount  of  laceration  of  a  wound 
that  is  of  consequence,  but  the  soiling  of  it  with  earth.  No  doubt  the 
soiling  is  more  likely  to  be  great  where  the  wound  is  torn  than  where  it 
is  simply  a  clean  incision. 

Causes  Of  Death. — The  causes  of  death  in  tetanus  are:  (i)  laryngeal 
spasm,  (2)  pressure  of  the  trachea  against  the  spine,  in  cases  of  bad  opis- 
thotonos,  (3)  spasm  of  the  diaphragm  or  other  respiratory  muscles,  (4)  arrest 
of  the  heart's  action  either  from  spasm  or  paralysis,  (5)  exhaustion  and 
inanition,  and  (6)  hyperpyrexia. 

Treatment. — Prophylactic. — In  the  treatment  of  tetanus  prevention 
is  naturally  the  first  point,  and  as  tetanus  in  aseptic  wounds  is  quite  unknown, 
it  is  clear  that  strict  purification  of  wounds  likely  to  be  infected  with  the 
tetanus  bacillus  must  be  carried  out.  Hence  in  all  cases  where  a  wound 
is  soiled  with  earth,  and  where  lacerated  wounds  have  occurred  from  falls 
in  stables,  gardens  and  so  forth,  the  wound  must  be  very  thoroughly  purified, 
a  nail-brush  being  used  to  scrub  away  the  earth,  and  the  whole  wound 
thoroughly  sponged  out  with  undiluted  carbolic  acid.  For  further  details 
concerning  the  purification  of  wounds  see  p.  191. 

Curative. — When  the  disease  is  established  there  is  at  present  at 
our  disposal  the  anti-tetanic  serum,  which  is  undoubtedly  effectual  in  a  very 


222  WOUNDS. 

considerable  number  of  cases,  and  this  is  the  first  remedy  that  should  be 
employed.  An  injection  of  anti-tetanic  serum  (which  is  the  serum  of 
horses,  or  other  animals  which  have  been  rendered  immune  to  tetanus) 
must  be  introduced  in  a  large  dose  in  the  first  instance,  and  must  be 
repeated  at  intervals  of  from  12  to  24  hours,  the  exact  amount  being 
determined  by  the  effect  produced.  It  is  well  to  begin  with  20  c.c.,  and  to 
repeat  the  dose  in  from  12  to  24  hours,  according  to  its  effect  on  the  spasms. 
This  should  be  again  repeated  every  12  or  24  hours  if  necessary.  The 
effect  of  the  serum  is  sometimes  very  remarkable,  but  it  is  not  immediate, 
and  the  spasms  may  recur  after  its  use  so  severely  as  to  require  the  adminis- 
tration of  chloroform;  they  usually  recur,  however,  at  longer  intervals 
and  with  less  severity. 

Treatment  of  the  Wound. — In  the  early  stage  also,  the  wound  should  be 
thoroughly  cleaned  out  We  do  not  know  the  exact  modus  operandi  of  the 
tetanus  bacillus,  though  it  is  seldom  limited  to  the  wound,  but  nevertheless  it 
is  well,  in  the  first  place,  to  give  the  patient  chloroform,  thoroughly  open  up 
the  wound  and  wash  away  all  the  decomposing  material,  and  then  to  clip  away 
any  gangrenous  shreds,  thoroughly  sponge  the  wound  out  with  pure  carbolic 
acid,  and  stuff  it  with  cyanide  gauze  sprinkled  with  iodoform.  After  this 
has  been  done  the  dressing  need  not,  as  a  rule,  be  disturbed  for  two  or  three 
days,  so  that  the  patient  is  saved  the  pain  and  the  risk  of  convulsions 
involved  in  attention  to  the  wound.  Amputation  is  frequently  performed 
in  cases  of  wounds  of  the  extremities,  but,  as  the  disease  has  generally 
established  itself  in  the  system,  the  operation  is,  as  a  rule,  quite  useless,  and 
may  be  hurtful  from  the  pain  and  disturbance  it  causes.  If  anything  at  all 
is  to  be  effected  by  local  treatment,  as  much  will  be  done  by  thorough  dis- 
infection of  the  wound  as  by  amputation,  and  this  with  much  less  risk  to 
the  patient 

Drugs. — Whether  the  serum  be  injected  or  not,  it  is  necessary  to 
administer  sedatives,  and  the  one  most  in  vogue  is  chloral.  It  should  be 
given  in  large  doses,  so  that  in  the  course  of  24  hours  an  adult  shall 
have  as  much  as  150  or  even  200  grains.  Care  must  of  course  be  taken 
not  to  poison  the  patient  with  the  drug,  as  has  undoubtedly  happened  in 
some  cases,  but  usually  the  amount  mentioned  can  be  administered  in  the 
course  of  24  hours  without  risk.  When  there  is  inability  to  swallow,  the  drug 
may  be  administered  by  the  rectum.  Bearing  in  mind  also  the  fact  that  the 
slightest  noise  or  disturbance  is  very  likely  to  bring  on  a  spasm,  the  patient 
should  be  completely  isolated.  He  should  be  placed  in  a  room  which  is 
thickly  carpeted,  and  complete  silence  should  be  maintained,  and  it  is  well 
to  wrap  up  all  the  exposed  portions  of  the  body  in  cotton  wool,  so  as  to 
avoid  any  irritation  to  the  surface  of  the  skin  from  the  impact  of  cold 
air,  etc. 

When  the  spasms  are  very  severe  and  threaten,  for  example,  either  to 
produce  a  condition  of  dangerous  hyperpyrexia,  or  to  cause  death  from 
•obstruction  to  the  respiration,  chloroform  should  be  at  once  administered. 


TETANUS. 


223 


When  the  patient  is  under  the  influence  of  the  anaesthetic,  the  spasm  rapidly 
subsides,  and  repeated  administrations  may  be  called  for  in  bad  cases. 
When  the  patient  is  unable  to  swallow,  advantage  should  be  taken  of  the 
administration  of  the  anaesthetic  to  introduce  suitable  nourishment  into  the 
stomach  by  means  of  a  stomach  tube ;  the  opportunity  may  also  be  taken  to 
give  a  nutrient  enema.  Morphine,  in  doses  of  ^-th  of  a  grain  subcutaneously, 
may  also  be  given  every  three  or  four  hours,  but  among  drugs  the  chief 
reliance  is  to  be  placed  on  chloral  and  chloroform.  When  hyperpyrexia 
occurs  the  temperature  should  be  reduced  by  sponging  with  tepid  water 
(see  p.  215)  or  by  cold  wet  packing.  The  former  is  preferable,  as  cold 
water  is  very  apt  to  set  up  a  spasm.  Should  sponging  fail  to  reduce  the 
temperature  it  may  however  be  necessary  to  have  recourse  to  wet  packing, 
which  is  done  as  follows.  A  mackintosh  is  put  under  the  patient  who  is 
then  wrapped  up  in  a  sheet  wrung  out  of  iced  water.  A  blanket  is  thrown 
over  him  and  he  is  left  in  the  wet  pack  for  from  five  to  fifteen  minutes. 
At  the  end  of  this  time  the  sheet  and  the  mackintosh  are  removed,  and 
the  patient  is  carefully  dried  and  covered  with  the  bedclothes. 

Diet. — As  far  as  possible  the  strength  should  be  kept  up  by  proper 
nourishment ;  indeed,  this  is  a  most  essential  part  of  the  treatment,  and 
the  great  majority  of  cases  where  the  patient  cannot  swallow  end  fatally. 
Stimulants  may  also  be  necessary  towards  the  end  of  the  disease.  If  the 
patient  cannot  swallow,  and  especially  if  the  attempts  to  do  so  produce  con- 
vulsions, it  is  necessary  to  resort  to  rectal  feeding ;  great  care  must,  however, 
be  taken  to  disturb  the  patient  as  little  as  possible  in  introducing  the  food 
into  the  rectum.  For  this  purpose  zyminised  suppositories  are  of  great 
value ;  one  should  be  introduced  every  four  hours,  and  every  two  hours 
after  the  suppository  a  beef-tea  enema  should  be  given.  The  enema  should 
be  small,  about  two  ounces  of  Bovril  at  a  time  being  sufficient;  it  is  best 
to  peptonise  it  before  it  is  introduced  (see  p.  83).  Later  on  in  the  disease, 
when  the  patient  is  becoming  exhausted,  it  may  be  necessary  to  administer 
stimulants  along  with  the  beef-tea  enemata.  Watch  should  be  kept  to  see 
that  the  urine  is  passed,  for  the  bladder  is  very  apt  to  become  distended, 
and  from  time  to  time  of  course  the  bowels  should  be  washed  out  with  an 
injection  of  warm  water.  Above  all  things,  care  should  be  taken  to  avoid  all 
sudden  movements,  and  to  be  as  gentle  in  manipulating  the  patient  as 
possible. 


CHAPTER   XI. 

AFFECTIONS   OF  CICATRICES. 

CHELOID. 

WHILE  in  cases  in  which  union  by  first  intention  has  occurred,  the  cicatrix 
is  usually  healthy,  this  is  not  invariably  the  case,  and  when  the  wound  is 
large  and  has  been  allowed  to  heal  by  granulation,  the  scar  left  is  very 
often  unsatisfactory.  In  either  case  the  affection  known  as  false  cheloid 
or  thickened  cicatrix  may  be  met  with  in  certain  patients.  In  this  condition 
the  cicatrix  becomes  much  thickened,  and  raised  above  the  surface  of 
the  surrounding  skin;  where  the  scar  is  linear  there  is  a  hard  raised 
bar  of  this  cheloid  material,  corresponding  to  the  line  of  incision,  and 
where  it  is  a  broad  one  the  affection  generally  begins  along  the  line  of 
junction  of  the  skin  and  the  cicatricial  tissue,  and  spreads  thence  throughout 
the  rest  of  the  scar.  Where  the  scar  is  broad  a  most  unsightly  deformity  is 
produced  as  the  surrounding  parts  are  pulled  upon  and  puckered  up. 
The  scar  does  not  yield  as  ordinary  scar  tissue  should,  and  the  cheloid  itself 
is  painful,  and  is  liable  to  become  ulcerated. 

Causes. — The  cause  of  this  condition  is  by  no  means  clear.  It  would 
appear  that  there  is  a  special  tendency  for  it  to  affect  scars  in  those  who  are  or 
have  been  the  subjects  of  tuberculous  disease,  but  it  also  occurs  in  those  in 
whom  there  is  no  such  tendency,  and  in  them  it  is  not  uncommon  to  find 
that  every  scar — even  down  to  a  pin-  or  needle-prick — will  harden  and 
become  cheloid.  As  regards  the  nature  of  this  thickening,  the  microscope 
reveals  simply  a  large  number  of  young  cells  and  granulation  tissue. 

Cheloid  scars,  especially  if  quite  small,  sometimes  disappear  in  the  course 
of  time,  but  such  a  termination  is  very  uncertain  and  cannot  be  confidently 
reckoned  on. 

Treatment. — The  condition  is  one  that  is  excessively  difficult  to  get 
rid  of,  and,  as  far  as  our  present  knowledge  goes,  it  cannot  be  prevented ; 
neither  can  its  occurrence  be  anticipated.  When  it  is  seen  that  it  is  about 
to  occur,  i.e.  when  the  scar  shows  signs  of  thickening,  the  best  treatment 
is  to  try  to  diminish  the  vascularity  of  the  part.  This  may  be  done  in 
various  ways,  more  particularly  by  pressure,  exerted  either  by  strapping, 


CHELOID.  225 

by  the  application  of  collodion,  or  by  a  firm  bandage.  Perhaps  the  simplest 
method  is  to  paint  the  scar  with  ordinary  (not  flexile)  collodion ;  as  this 
dries  it  contracts,  and  by  compressing  the  small  vessels  diminishes  the 
blood  supply  of  the  scar.  This  method  is  strongly  to  be  recommended 
in  the  early  stage ;  but  it  is  not  likely  to  do  so  much  good  when  the 
cheloid  condition  is  well  developed.  In  applying  pressure  of  any  kind 
it  should  be  borne  in  mind  that  ulceration  is  very  apt  to  occur  in  large 
cheloids,  and  even  the  application  of  collodion  may  sometimes  precipitate 
the  onset  of  the  ulceration. 

Cod  liver  oil  should  also  be  regularly  administered  internally,  a  dessert- 
spoonful to  a  tablespoonful  of  cod  liver  oil  or  one  of  its  emulsions,  such 
as  Scott's  or  Mellin's,  being  given  about  four  times  a  day.  Some  surgeons 
recommend  scarification  of  the  scar  with  a  lancet  or  a  fine  electric  cautery 
point,  but  it  is  doubtful  whether  any  real  permanent  benefit  results  from  this 
plan  of  treatment. 

The  question  of  the  advisability  of  excising  a  cheloid  is  one  which  con- 
stantly arises  and  which  has  been  much  debated,  but  the  great  objection 
to  the  procedure  is  that  the  scar  resulting  from  the  operation  will  almost 
certainly  become  cheloid  in  its  turn ;  this  applies  not  only  to  the  scar  itself 
but  also  to  the  stitch  tracks  adjacent  to  it.  When  a  considerable  area  of  skin 
has  been  excised,  and  there  is  so  much  tension  on  the  stitches  that  they 
cut  their  way  through  the  skin  for  some  distance,  a  very  unsightly  appearance 
is  presented  should  they  become  cheloid.  At  the  same  time  in  certain  cases 
it  seems  to  be  quite  justifiable  to  remove  the  mass  even  at  the  risk  of  linear 
cheloid  subsequently  resulting.  For  example,  where  there  is  a  broad  ulcer- 
ating cheloid  leading  to  much  contraction  and  great  inconvenience,  it  is 
well  to  excise  it,  so  long  as  the  skin  around  is  sufficiently  lax  to  allow 
the  edges  to  come  together  without  marked  tension  after  they  have  been 
freely  undermined ;  the  old  broad  scar  is  thus  converted  into  a  linear  one. 
In  doing  this  it  should  be  borne  in  mind  that  the  stitch  tracks  will  have  a 
great  tendency  to  become  cheloid,  and,  therefore,  if  possible  no  sutures 
should  be  inserted  through  the  skin ;  the  method  of  buried  stitches,  re- 
commended on  p.  154,  should  be  employed,  deep  catgut  stitches  being 
inserted,  through  the  subcutaneous  tissue  only,  from  the  points  where  the 
undermining  ceases  on  the  one  side  to  the  corresponding  points  on  the  other, 
so  as  to  relieve  the  tension  on  the  edges.  The  latter  are  then  approximated 
by  stitches  passing  through  the  fat  and  the  deeper  parts  of  the  skin,  the 
superficial  margins  being  brought  together  by  strips  of  gauze  fixed  on  with 
collodion.  A  very  narrow  cicatrix  is  thus  obtained,  and  should  this 
become  cheloid  it  is  not  a  matter  of  great  importance ;  sometimes  the 
condition  does  not  recur.  Excision  of  cheloids  cannot,  however,  be  recom- 
mended when  a  large  raw  surface  will  be  left,  as,  even  if  this  be  skin-grafted, 
the  condition  is  apt  to  reappear  at  the  edges  of  the  grafts,  and  spread  over 
the  whole  surface  of  the  wound. 


226  AFFECTIONS   OF   CICATRICES. 


CONTRACTING   CICATHIX. 

This  is  a  very  serious  condition  under  certain  circumstances.  Even 
cicatrices  resulting  from  healing  by  first  intention  sometimes  contract  so 
much  as  to  cause  a  good  deal  of  interference  with  movement.  This  is 
very  well  seen  where  thyroid  tumours  have  been  excised  by  vertical  in- 
cisions in  the  middle  line  of  the  neck ;  if  the  cicatrix  contracts  to  any 
extent,  a  band  is  formed  between  the  sternum  and  the  trachea  which 
interferes  with  the  due  extension  of  the  head  upon  the  trunk  and  often 
causes  much  inconvenience. 

Treatment. — In  cases  such  as  the  above,  the  cicatrix  should  be  divided 
transversely  about  its  centre,  the  skin  and  cicatricial  tissue  undermined,  and 
the  divided  ends  of  the  scar  pulled  well  asunder.  It  is  then  generally  possible, 
to  bring  together  the  lateral  angles  of  the  lozenge-shaped  incision  thus  pro- 
duced and  so  to  convert  the  transverse  into  a  longitudinal  wound,  which 
is  then  stitched  up  and  the  scar  thus  elongated.  In  cases  where,  after  burns, 
the  surgeon  has  to  do  with  a  very  large  cicatrix,  all  tense  bands  should  be 
divided  in  this  manner,  and  the  raw  surface  left  after  separation  of  the 
ends  of  the  cicatrix  should  be  grafted  upon  at  once ;  owing  to  the  extent  of 
the  affected  area  it  will  not  be  possible  to  suture  it  in  the  manner  just 
described.  There  are  many  other  methods  of  dealing  with  the  deformities 
caused  by  cicatrices  in  special  situations  which  will  be  discussed  under 
their  proper  headings. 

PAINFUL   CICATRIX. 

% 

Cicatrices  are  sometimes  met  with  which  are  intensely  tender,  so  that  the 
slightest  touch  causes  exquisite  pain,  which  is  usually  neuralgic  in  character, 
and  radiates  from  the  scar.  These  painful  scars  most  commonly  occur 
when  the  edges  of  a  wound  have  not  been  brought  accurately  together,  but 
they  may  be  met  with  even  where  healing  by  first  intention  has  occurred, 
and  they  indicate  the  implication  of  nerves  in  the  contracting  fibrous  tissue 
of  the  scar. 

Treatment. — The  only  satisfactory  treatment  in  these  cases  is  to  dissect 
out  the  scar,  cutting  well  into  the  healthy  tissues  at  the  sides,  so  as  to  remove 
not  only  the  entangled  nerve  ends  which  may  have  already  become  bulbous, 
but  also  the  adjacent  and  probably  inflamed  portions.  When  there  is  a 
broad  scar  and  the  edges  of  the  wound  cannot  be  brought  together  after 
excision,  skin-grafting  (see  p.  50)  or  some  suitable  plastic  operation  is 
indicated. 


ADHERENT   CICATRIX. 

A  scar  may  be  adherent  to  the  tissues  beneath,  and  may  thus  become  a 
source  of  great  trouble  to  the  patient ;  besides  which,  these  scars  are  often 


EPITHELIOMA. 


227 


weak  and  readily  ulcerate.  For  example,  in  the  case  of  a  sore  over  the 
tibia,  the  scar  may  become  fixed  to  the  bone,  and  is  then  very  liable  to 
break  down  and  ulcerate  after  comparatively  slight  injuries  which  would  not 
affect  it  were  it  freely  moveable.  The  same  is  also  the  case  with  scars  over 
the  ends  of  bones  after  amputation.  Should  they  become  adherent  to  the 
bone,  the  amount  of  discomfort  and  pain  which  they  cause  is  extreme,  and, 
as  will  be  pointed  out  in  dealing  with  amputations,  it  is  one  of  the  essentials 
of  a  good  stump  that  the  scar  should  not  be  adherent  to  the  end  of  the  bone. 
Treatment. — In  cases  of  adherent  cicatrix  after  amputation,  the 
obvious  remedy  is  to  open  up  the  flaps,  release  the  adhesions,  and,  if 
necessary,  remove  a  slice  of  the  bone.  In  other  cases,  where  the  surgeon 
has  to  do  with  a  scar  adherent  to  such  structures  as  bones,  tendons  or 
muscles,  an  attempt  may  be  made,  where  the  adhesion  is  slight,  to  divide  it 
by  a  tenotomy  knife  introduced  through  the  skin  at  the  margin  of  the  scar. 
Generally,  however,  it  is  best  to  dissect  out  the  scar  altogether,  and  then,  by 
means  of  a  plastic  operation,  to  turn  in  a  flap  from  the  side  so  as  to  cover 
the  raw  surface  thus  made  ;  the  surface  from  which  the  flap  is  taken  may 
be  skin-grafted  (see  p.  50)  if  its  edges  cannot  be  brought  together.  This 
is  preferable  to  grafting  directly  over  bone,  to  which  the  grafts  might  in  their 
turn  become  adherent.  In  some  of  these  cases  it  has  been  suggested  that 
portions  of  the  underlying  bone  should  be  removed,  so  as  to  shorten  the 
limb  and  to  relieve  the  tension  on  the  wound  left  after  excision  of  the  scar, 
so  that  its  edges  can  be  brought  together.  Although  this  operation  has 
been  more  than  once  practised,  it  can,  however,  only  be  called  for  in  extreme 
cases ;  in  the  large  majority  the  method  just  described  will  suffice. 


EPITHELIOMA. 

Another  reason  for  getting  rid  of  scars  which  form  adhesions  to  the 
deeper  parts,  or  those  which  are  constantly  in  a  state  of  irritation,  is  that, 
as  the  patient  gets  older,  such  scars  are  very  apt  to  become  the  seat  of 
malignant  growths,  more  particularly  .epithelioma.  Perhaps  the  most 
common  seat  of  epitheliomata  in  the  extremities  is  an  old  adherent  scar, 
round  the  orifice  of  a  sinus,  etc.,  and  this  is  a  point  which  should  be 
carefully  borne  in  mind  in  treating  these  conditions. 

Treatment. — The  treatment  of  epithelioma  affecting  scars  is  the  same 
as  the  treatment  of  the  disease  elsewhere,  namely  free  excision  of  the 
diseased  area  and  examination,  and,  if  necessary,  excision  of  the  nearest 
lymphatic  glands.  The  exact  nature  of  the  operation  will  depend  upon  the 
situation  and  extent  of  the  disease,  but  there  should  be  no  hesitation  in 
removing  it  very  freely,  even  by  amputation  if  necessary.  Recurrence  is 
less  frequent  after  operation  for  epithelioma  in  the  extremities  than  else- 
where, and  this  is  partly  due  to  the  fact  that  there  is  plenty  of  room 
for  wide  removal  of  the  disease. 


CHAPTER   XII. 

SYPHILIS. 

SYPHILIS  is  an  infective  disease,  probably  of  a  bacillary  nature,  which 
has  a  period  of  incubation  and  a  more  or  less  regular  succession  of 
symptoms.  The  disease  may  be  acquired,  usually  as  the  result  of  impure 
sexual  connection,  or  it  may  be  inherited ;  in  the  latter  case  it  is  called 
congenital.  It  is  generally  divided  into  three  stages  or  periods. 

ACQUIRED   SYPHILIS. 

Primary  Stage. — The  first  manifestation  of  acquired  syphilis  appears 
as  an  induration  at  the  seat  of  innoculation,  commonly  termed  a  "hard" 
or  "  Hunterian "  chancre,  which  generally  undergoes  ulceration.  This  in- 
duration arises  at  any  time  from  ten  days  to  eight  weeks  after  infection:  it  most 
commonly  occurs  about  the  fourth  week.  It  is  followed,  first  by  enlargement 
of  the  nearest  lymphatic  glands,  and  subsequently  of  those  in  other  parts  of 
the  body.  The  induration  at  the  seat  of  innoculation,  and  the  enlargement  of 
the  nearest  lymphatic  glands  are  the  phenomena  usually  included  under 
the  term  "Primary  Syphilis." 

Secondary  Stage. — Following  the  primary  condition,  and  usually 
commencing  within  three  months  after  infection,  a  series  of  inflammatory 
phenomena  affect  the  skin,  mucous  membranes,  fibrous  tissues,  periosteum, 
etc.,  and  these  phenomena  appear  at  intervals  and  are  spread  over  a  period 
of  time,  the  length  of  which  varies  with  the  severity  of  the  attack,  but 
which  roughly  speaking  lasts  about  two  years.  The  early  phenomena  are 
usually  the  mildest  and  the  most  superficial,  but,  as  time  goes  on,  the 
lesions  become  of  a  severer  type  and  are  more  deeply  seated.  During  this 
period,  which  is  spoken  of  as  that  of  "Secondary  Syphilis,"  are  seen  such 
affections  as  erythematous,  papular,  squamous,  pustular,  and  nodular  or 
tuberculated  syphilides  on  the  skin,  and  the  occurrence  of  mucous  patches 
or  condylomata  on  the  skin  or  mucous  membranes.  There  is  also 
frequently  alopecia,  due  either  to  simple  mal-nutrition  of  the  hair  caused 
by  syphilis,  or  resulting  from  pustular  syphilides  of  the  scalp ;  in  the 


ACQUIRED    SYPHILIS.  229 

former  case  it  is  temporary,  the  hair  growing  again  as  the  patient  recovers, 
in  the  latter,  the  loss  of  hair  is  permanent.  Periostitis  may  also  occur  and 
if  left  untreated  may  lead  to  permanent  bony  formations  or  nodes.  Iritis 
and  other  rarer  affections  are  also  met  with  in  the  secondary  period. 

Tertiary  Stage. — Following  the  secondary  stage,  there  are  other 
phenomena  which  are  spoken  of  as  lesions  of  "Tertiary  Syphilis";  these 
may  follow  immediately  upon  those  of  the  secondary  stage  or  they  may 
occur  before  the  latter  reaches  its  termination.  Usually  however  they  do 
not  appear  until  a  considerable  interval  has  elapsed,  the  patient  having 
enjoyed  in  the  meanwhile  many  years  of  apparently  perfect  health.  They 
take  the  form  principally  of  gummata  or  fibrosis  in  the  various  tissues  and 
organs  of  the  body,  or  obstinate  ulcerations  of  the  skin  or  mucous 
membranes. 

These  remarks  will  suffice  to  define  the  disease,  but  it  must  not  be 
forgotten  that  during  the  course  of  syphilis  the  general  health  is  often 
markedly  affected,  and  this  is  more  especially  the  case  during  the  early- 
secondary  period,  when  the  patient  becomes  pale,  weak  and  cachectic 
and  the  red  blood  corpuscles  are  diminished  in  number  and  lose  a  con- 
siderable proportion  of  their  haemoglobin.  At  this  stage  too  there  is  often 
marked  pyrexia. 

Treatment. — The  treatment  of  the  various  lesions  in  the  different 
tissues  and  organs  will  be  dealt  with,  in  so  far  as  they  call  for  special 
treatment,  when  we  come  to  deal  with  affections  of  the  particular  organ 
or  tissue.  Here  we  shall  only  refer  to  the  treatment  of  syphilis  in  general. 

Prophylaxis. — From  this  point  of  view  it  is  well  to  enumerate  some 
of  the  chief  sources  and  modes  of  contagion  of  syphilis ;  the  prophylaxis 
will  obviously  consist  in  avoiding  them.  The  most  common  source  of 
infection  is  perhaps  the  secretion  from  the  primary  sore,  but  a  very  potent 
factor  in  the  spread  of  the  disease  is  the  discharge  from  secondary  lesions, 
such  as  mucous  papules  and  condylomata;  the  blood  also  is  infective 
during  the  secondary  stage,  and  this  infectivity  is  at  its  height  when 
syphilitic  manifestations  are  actually  present.  The  usual  mode  of  con- 
tagion is  of  course  by  sexual  connection.  Kissing  is  also  a  means  of 
spreading  the  disease  where  secondary  symptoms  are  present  in  the  mouth 
or  throat;  in  suckling  also,  infection  may  be  conveyed  from  child  to 
nurse  or  vice  versa ;  simple  sores  may  also  become  inoculated,  as  occurs 
frequently  on  the  fingers  of  medical  men ;  in  the  Jewish  rite  of  circumcision 
a  similar  accident  has  occurred.  Infection  may  also  be  conveyed  by 
vaccination,  should  the  blood  of  a  syphilitic  infant  by  chance  con- 
taminate the  vaccine  lymph ;  lastly,  it  may  be  communicated  by  the 
employment  of  infected  utensils,  such  as  cups,  spoons,  pipes,  toys,  etc., 
which  have  been  used  by  those  suffering  from  the  secondary  stage  of 
the  disease. 

In  considering  the  treatment  of  syphilis  we  shall  discuss  it  in  relation 
to  the  three  clinical  stages  of  the  disease,  namely,  primary,  secondary,  and 


230  SYPHILIS. 

tertiary  syphilis.  It  is  interesting  to  note  that,  although  the  division 
between  secondary  and  tertiary  syphilis,  more  particularly  in  respect  to 
the  time  limit,  is  somewhat  arbitrary,  a  further  justification  for  this 
division  is  found  in  the  fact  that  the  two  drugs  which  exercise  a  specific 
influence  on  the  disease,  namely,  mercurial  preparations  and  the  iodides 
(especially  those  of  potassium  and  sodium),  act  differently  in  these  two 
stages.  During  the  early  secondary  stage  the  iodides  have  little  or  no 
effect  in  causing  the  disappearance  of  the  lesions,  while  mercury  acts  much 
more  effectually.  During  the  tertiary  stage,  on  the  other  hand,  the  iodides 
are  much  more  rapid  in  their  action  than  is  mercury. 

Primary  Syphilis. — (</)  Local  Treatment. — Here  attention  must  be 
chiefly  directed  to  the  local  treatment  of  the  sore.  In  the  first  place,  care 
must  be  taken  to  avoid  the  use  of  irritating  applications  :  they  only  lead  to 
enlargement  of  the  sore  and  absorption  of  a  still  larger  dose  of  the  poison. 
No  attempt  should  be  made  to  destroy  the  chancre  by  caustics :  they  never 
cause  the  disease  to  abort,  and  only  serve  to  produce  extension  of  the 
ulceration.  Excision  of  chancres  is  also  not  to  be  recommended.  In  the 
great  majority  of  cases,  by  the  time  the  diagnosis  can  be  made  with 
certainty,  the  infection  has  spread  far  beyond  the  seat  of  inoculation,  and 
there  is  no  chance  of  cutting  short  the  disease  by  removing  the  sore. 
During  the  early  period,  while  the  diagnosis  is  still  uncertain,  absolute 
cleanliness,  frequent  washing  with  water  or  boracic  lotion  and  the 
application  of  a  weak  boracic  ointment  (^  strength)  or  boracic  lint, 
should  be  relied  upon.  When  the  diagnosis  is  certain,  it  is  well  to  employ 
mercurials  locally  and  the  favourite  application  is  weak  lotio  nigra  (3 
grains  of  calomel  to  the  ounce  of  lime  water)  with  which  the  sore  is 
washed  three  or  four  times  daily,  after  which  a  piece  of  lint  soaked  in 
the  lotion  is  applied  over  its  surface.  The  penis,  if  that  be  the  part 
affected,  should  be  kept  in  a  bag  made  by  sewing  boracic  or  salicylic 
wool  between  two  layers  of  gauze :  this  prevents  friction  and  avoids 
soiling  of  the  linen.  Where  the  sore  is  large  and  extending  it  is  well 
after  drying  the  sore  to  dust  it  over  with  calomel  and  starch  (calomel 
one  part,  starch  powder  three  parts),  two  or  three  times  a  day;  where 
sloughing  is  taking  place  or  where  the  discharge  is  offensive,  one  part 
of  iodoform  may  be  added  to  this.  Lint  dipped  in  lotio  nigra  is  then 
applied  as  before  to  the  surface  of  the  ulcer.  When  the  chancre  begins 
to  heal,  it  is  well  to  abandon  the  local  use  of  mercurials  and  to  return 
to  the  boracic  lotion  and  weak  boracic  ointment. 

In  the  case  of  the  acutely  spreading,  so-called  phagedenic  chancre  it 
is  well  to  bring  the  patient  rapidly  under  the  influence  of  mercury,  especially 
if  the  chancre  be  situated  where  its  spread  may  do  serious  harm ;  this 
should  be  in  addition  to  the  local  use  of  the  calomel,  starch  and  iodoform 
powder.  These  so-called  phagedenic  chancres,  although  not  true  phagedena, 
are  nevertheless  often  due  to  a  mixed  infection,  and  the  rule  as  to  the 
use  of  caustics  may  be  relaxed  here.  When  sloughing  actively  progresses  in 


ACQUIRED    SYPHILIS.  231 

spite  of  the  above  treatment,  it  is  advisable  to  scrape  the  surface  of  the  sore 
freely,  so  as  to  remove  all  the  sloughs,  and  then  to  apply  undiluted 
carbolic  acid  to  the  raw  surface ;  this  may  be  followed  by  dusting  with 
calomel  and  iodoform,  and  the  internal  administration  of  mercury  as 
before.  When  the  sore  is  small,  the  scraping  may  be  done  with  a  small 
sharp  spoon,  after  application  of  a  20  per  cent,  solution  of  cocaine  to  the 
ulcerated  surface.  If  it  be  large,  a  general  anaesthetic,  such  as  nitrous 
oxide,  may  be  required. 

(b}  General  Treatment. — A  much  debated  question  in  the  treatment  of 
primary  syphilis  is  whether  at  this  stage  mercury  should  be  given  internally 
or  whether  it  should  be  withheld  until  secondary  symptoms  make  their 
appearance.  In  this  country  many  surgeons  commence  mercurial  treatment 
directly  the  diagnosis  is  made,  but  abroad  most  of  the  leading  syphilographers 
condemn  the  use  of  mercury  in  syphilis  before  the  appearance  of  secondary 
symptoms,  unless  under  special  circumstances,  and  with  this  view  we  are 
in  the  main  disposed  to  agree.  The  reasons  given  are  that  the  adminis- 
tration of  full  doses  of  mercury  at  this  stage  has  a  depressing  effect  upon 
the  patient,  so  that,  when  it  is  required  for  the  treatment  of  secondary 
symptoms,  it  cannot  be  pushed  as  far  as  is  desirable  :  and  also  that  the 
diagnosis  of  a  syphilitic  chancre  is  seldom  beyond  the  possibility  of  a 
mistake,  and  the  patient  may  thus  be  salivated  or  submitted  to  a  tedious 
and  prolonged  course  of  mercury  unnecessarily.  In  certain  cases,  however,  it 
is  advisable  to  administer  mercury  during  the  primary  stage,  so  as  to  produce 
its  full  physiological  action.  This  is  called  for  in  the  rapidly  spreading 
chancres  referred  to  above,  and  also  in  those  situated  where  the  loss  of 
tissue  they  cause  may  do  serious  harm,  as  for  example  upon  the  eyelid  ; 
in  married  people  and  in  the  case  of  chancres  on  doctors'  fingers  it  is 
advisable  to  employ  it  so  as  to  avoid  the  risk  of  infecting  others.  According 
to  some,  it  should  be  employed  in  the  case  of  women  infected  during 
pregnancy.  Where  patients  are  extremely  nervous  and  frightened,  it  is 
also  well  to  give  mercury  in  small  doses  during  the  primary  stage,  but  not 
necessarily  in  sufficient  quantity  to  produce  its  physiological  effects. 

During  the  primary  stage  the  use  of  iron  is  of  great  value,  and  one 
of  the  best  preparations  is  Blaud's,  given  in  doses  of  5  to  10  grains  three 
times  daily  immediately  after  food ;  it  is  best  administered  in  the  form 
of  capsules  or  cachets.  Benefit  is  often  experienced  in  very  cachectic 
subjects  from  the  use  of  Easton's  syrup  two  or  three  times  a  day,  in 
doses  of  half  a  drachm  in  a  wineglassful  of  water. 

Secondary  Syphilis. — (a)  General  Treatment. — In  the  treatment  of 
the  secondary  stage  the  principal  drug  employed  is  mercury,  and  the  chief 
points  to  be  considered  are  in  connection  with  its  administration.  During 
the  secondary  period,  whilst  mercury  is  being  taken,  the  following  points 
should  be  attended  to.  (i)  The  diet  should  be  carefully  ordered,  only 
plain  and  nourishing  food  being  taken,  whilst  all  indigestible  matters, 
spices  and  condiments  should  be  avoided. 


232  SYPHILIS. 

(2)  As  far  as  possible,  alcohol  should  be  given  up,  but  where  patients 
are  accustomed  to  take  it  regularly,  a  small  amount,  preferably  light  claret, 
may  be  allowed. 

(3)  Regular  exercise  should  be  taken,  but  the  more  violent  forms,  such 
as   football,  hunting,  and    the  like,  must  be  avoided,  as  otherwise   greater 
quantities  of  mercury  will  be  required  to  bring  the  patient  properly  under 
its  influence.     It  has  long  been  recognised  that  all  persons  taking  mercury 
are  particularly  prone  to  catarrhs  which  are  apt  to  be  of  a  severe  type. 

(4)  The  care  of  the   teeth  is  of  the  highest  importance.      If  tartar  be 
allowed  to  accumulate   on   them,   salivation    may  occur  before  the  patient 
is  fully  under  the  influence  of  the  drug,   and  there  may  be  considerable 
difficulty  in  continuing  the  mercury,  on  account  of  the  premature  tenderness 
of  the  gums.     The  patient  should  be  enjoined  to  brush  the  teeth  frequently 
during  the  day,  and  if  there  be  any  tenderness,  an  astringent  mouth-wash, 
such   as  a   combination   of  alum  and   tincture  of  myrrh,    may  be  usefully 
employed. 

(5)  Smoking  should  be  prohibited,  both  on  account  of  the  depressing 
effect  of  tobacco  and  especially  because  the  irritation  of  the  smoke  pre- 
disposes to  and  keeps  up  throat,  mouth,  and  tongue  affections. 

Modes  of  Administration  of  Mercury. — Mercury  may  be  administered 
by  the  mouth,  by  the  skin,  and  by  intra-muscular  injection.  Among  the 
various  preparations  of  the  drug  administered  by  the  mouth,  the  metallic 
form  acts  best  during  the  early  stages,  and  is  usually  given  either  in  the 
form  of  blue  pill  or  as  a  pill  of  hydrargyrum  cum  creta.  In  this  stage  also 
it  is  well  to  combine  it  with  iron,  and  the  following  is  a  good  formula  : 

R.       Pil.  hydrargyri,  -         -          -          -  -         gr.    2. 

Ferri  sulphatis,  -  gr.    i. 

Extract,  opii,     ....  -         gr.  ^. 

M.  ft.  pil.     One  pill  to  be  taken  thrice  daily. 

"  Hutchinson's  formula  "  consists  of  hydrarg.  c.  cret.  and  Dover's  powder 
in  equal  quantities  made  up  into  4-grain  pills,  one  of  which  is  taken  four 
times  a  day.  The  amount  of  Dover's  powder  should  be  varied  according 
to  the  action  of  the  mercury  upon  the  bowels.  The  quantity  of  mercury 
in  the  pill  may  be  gradually  increased,  so  long  as  no  intestinal  irritation  is 
produced,  and  the  full  doses  are  pushed  until  the  mercury  begins  to  manifest 
its  physiological  effects,  as  shown  by  salivation  or  soreness  of  the  gums. 
When  this  stage  is  reached,  the  dose  should  be  reduced,  or  if  the  tenderness 
of  the  gums  be  extreme,  the  drug  may  be  discontinued  entirely  for  two  or 
three  days  until  the  tenderness  has  passed  off,  when  it  may  be  resumed  in 
smaller  doses.  It  should  not  be  discontinued  altogether  when  the  physio- 
logical effects  manifest  themselves ;  as  a  rule  the  secondary  phenomena  do 
not  disappear  until  the  physiological  action  of  the  mercury  is  apparent. 

At  a  later  stage  of  secondary  syphilis,  particularly  in  weakly  subjects, 
other  forms  of  mercury  often  act  better,  and  give  rise  to  less  intestinal 
irritation  than  the  one  just  described.  The  green  iodide  of  mercury,  for 


ACQUIRED    SYPHILIS.  233 

example,  is  a  very  useful  drug ;  it  may  be  given  in  pill  form,  in  doses  of 
a  quarter  to  half  a  grain  combined  with  a  quarter  of  a  grain  of  extract  of 
opium,  three  or  four  times  a  day.  In  the  late  secondary  stage,  and  especially 
where  the  patient  is  very  anaemic  and  feeble,  the  French  preparation  known 
as  "  Gibert's  syrup,"  is  often  extremely  good.  Each  ounce  of  this  contains 
TV th  of  a  grain  of  biniodide  of  mercury,  5  grains  of  iodide  of  potassium,  syrup, 
and  water.  The  longer  the  syphilis  has  lasted  the  better  in  fact  is  the  result 
obtained  by  combining  iodide  of  potassium  with  the  mercury. 

An  important  question  is,  how  long  the  mercury  should  be  continued,  for 
there  seems  good  reason  to  believe  that,  in  the  milder  cases  of  syphilis  at 
all  events,  an  actual  cure  may  be  brought  about  by  careful  treatment,  at  any 
rate  tertiary  symptoms  may  never  supervene.  Everyone  is  agreed  that  the 
mercury  should  be  continued  in  as  large  doses  as  possible  without  producing 
salivation,  at  least  until  the  secondary  symptoms,  for  which  it  is  admin- 
istered, have  subsided,  and  for  two  or  three  weeks  afterwards.  Also,  that 
when  fresh  symptoms  appear,  mercury  should  be  again  administered  as 
before.  Keyes,1  however,  has  pointed  out  that  it  is  well  to  continue  the 
treatment  with  small  doses  of  mercury  (about  one  third  of  the  dose  required 
to  produce  the  physiological  action)  after  the  symptoms  have  subsided. 
Should  these  recur,  the  full  dose  is  again  resorted  to.  He  advises  that 
this  treatment  be  continued,  with  two  or  three  weeks  interval  every  six 
months,  until  the  end  of  the  secondary  period,  in  fact  for  two  or  three 
years.  This  method  is  certainly  a  very  valuable  one,  and  we  would 
recommend  that  it  be  followed,  at  any  rate  for  a  year  or  eighteen  months. 

When  more  rapid  mercurialisation  is  required,  it  is  best  to  employ 
inunction,  and  in  the  later  stages  of  the  secondary  period  iodide  of  potassium 
should  be  administered  internally  at  the  same  time.  The  ointment  usually 
selected  for  inunction  is  the  ordinary  unguentum  hydrargyri,  but  the  same 
result  can  be  obtained  with  a  10  or  20  per  cent,  oleate  of  mercury  combined 
with  an  equal  quantity  of  lanoline  or  simple  cerate ;  this  preparation,  more- 
over, has  the  advantage  of  not  soiling  the  linen  to  such  an  extent  as  the 
blue  ointment  generally  does. 

Inunction  should  be  carried  out  as  follows.  Where  unguentum  hydrargyri 
is  used,  a  portion  about  the  size  of  a  hazel  nut  is  rubbed  well  into  the 
skin  every  night,  if  possible  before  a  warm  fire,  and  this  operation  should 
occupy  from  fifteen  to  twenty  minutes.  The  ointment  may  be  rubbed  into 
any  part  of  the  body  where  the  skin  is  comparatively  thin,  for  choice  into 
the  axillae  or  the  groins,  and  it  should  not  be  rubbed  into  the  same  part 
on  two  successive  nights,  as  otherwise  considerable  irritation  of  the  skin  may 
be  caused,  possibly  ending  in  the  formation  of  a  pustular  eruption.  For 
example,  the  inunction  should  be  made  into  one  axilla  on  the  first  night, 
into  the  other  the  following  night,  whilst  on  the  third  one  groin,  and 
on  the  fourth,  the  other  may  be  chosen ;  on  the  fifth  night  inunction  may  be 
employed  over  the  abdomen,  and  the  patient  should  wear  the  same  under- 
1  Keyes,  Venereal  Diseases,  1881. 


234  SYPHILIS. 

linen  and  should  not  have  a  bath  during  these  five  days.  At  the  end  of 
this  period  he  should  take  a  warm  bath,  and  then  commence  again  and  go 
on  in  this  way  till  the  gums  become  tender,  which  will  usually  be  in 
about  six  or  ten  days.  As  soon  as  this  happens,  the  patient  should 
have  a  warm  bath,  put  on  clean  linen,  stop  the  inunction,  and  substitute 
for  it  the  internal  use  of  mercurials,  such  as  2-grain  doses  of  pil.  hydrargyri 
combined  with  extract  of  opium,  three  or  four  times  daily,  as  already  detailed 
(see  p.  232).  If,  under  this  treatment,  the  condition  of  the  gums  gets  worse, 
the  dose  of  pil.  hydrargyri  should  be  reduced  ;  if,  on  the  other  hand,  it 
improves,  the  dose  may  be  slightly  increased,  and  should  be  continued  till 
the  eruption  disappears,  and  for  two  or  three  weeks  afterwards,  when  it  may 
be  reduced  to  one  half  or  one  third  of  the  amount ;  this  must  be  continued 
for  a  considerable  time,  as  has  already  been  mentioned  (see  p.  233). 

Another  method  by  which  mercury  can  be  introduced  into  the  system 
through  the  skin  is  by  fumigation,  the  drug  employed  for  the  purpose 
being  calomel.  Fumigation  is  performed  by  means  of  a  vapour  bath 
which  is  best  taken  at  bed-time.  About  thirty  grains  of  calomel  are  placed 
in  a  small  metal  dish  which  is  surrounded  by  another  containing  a  little 
boiling  water,  and  the  whole  is  placed  over  a  spirit-lamp.  This  vaporizing 
apparatus  is  put  under  the  seat  of  a  cane  chair,  upon  which  the  patient, 
divested  of  his  clothes,  sits  surrounded  by  a  blanket  reaching  to  the 
floor,  and  tucked  tightly  round  the  neck  so  as  to  prevent  the  escape  of 
the  calomel  vapour.  It  takes  about  twenty  minutes  for  the  calomel  to  be 
volatilized,  and  the  patient  sits  meanwhile  in  a  profuse  perspiration,  so 
that  the  drug  is  readily  absorbed  through  the  skin.  After  the  sitting,  the 
patient  is  wrapped  in  a  blanket  and  goes  to  bed.  About  twice  a 
week  is  generally  sufficient  for  the  baths,  especially  if  the  patient  be  at  all 
weakly,  but  where  it  is  necessary  to  get  him  rapidly  under  the  influence 
of  mercury  one  may  be  given  every  night.  This  method  of  treatment  is 
especially  useful  for  obstinate  skin  affections,  but  otherwise  it  is  seldom 
employed :  the  smell  of  the  vaporizing  calomel  is  very  penetrating  and 
offensive. 

Lastly,  there  is  the  method  of  administration  by  infra-muscular  injection. 
This  is  a  very  satisfactory  plan  where  a  speedy  action  is  required,  as  for 
example  in  cases  of  rapidly  spreading  malignant  syphilis,  and  it  is  also 
very  useful  in  alcoholics,  who  get  intestinal  catarrh  very  readily  when 
the  drug  is  given  by  the  mouth,  so  that  there  is  imperfect  absorption 
from  the  alimentary  canal.  The  drug  employed  for  injection  is  either  the 
biniodide  of  mercury  (£th  to  \  of  a  grain)  dissolved  in  water,  or  the 
bichloride  (^th  of  a  grain)  with  a  little  glycerine  and  water  added.  The 
injections  should  be  made  two  or  three  times  a  week  or,  if  there  be  great 
urgency,  every  day.  A  fresh  place  should  be  chosen  on  each  occasion 
because  a  painful  lump  frequently  forms  at  the  seat  of  injection.  Further- 
more, the  injection  should  be  made  into  a  muscle,  preferably  into  that  of 
the  buttock.  A  largish  needle  should  be  used,  and  its  strength  must  be 


ACQUIRED    SYPHILIS.  235 

tested  carefully  each  time  before  use,  because  it  very  quickly  becomes 
eroded  and  might  break  off  in  the  tissues.  The  skin  should  be  disinfected 
by  rubbing  it  first  with  absolute  alcohol  and  then  with  1-20  carbolic  acid, 
and  the  needle  should  be  rapidly  inserted  deeply  at  right  angles  to  the 
skin,  care  being  taken  that  when  this  is  done  the  patient  does  not  start, 
as  otherwise  the  contraction  of  the  glutei  may  break  the  needle.  If  the 
muscle  be  firmly  pressed  upon  around  the  area  of  injection  it  will  tend 
to  prevent  any  sudden  contraction  when  the  needle  enters.  The  treatment 
is  continued  until  the  gums  become  tender,  and  then  Keyes'  method 
(see  p.  233)  may  be  resorted  to,  the  injections  being  resumed  if  any  fresh 
symptoms  make  their  appearance. 

(b)  Local  Treatment  in  secondary  syphilis  is  usually  of  considerable 
benefit ;  the  eruptions  are  often  favourably  affected  by  the  local  application 
of  mercury  in  one  of  its  different  forms.  Eruptions  on  the  face  may  often 
be  made  to  disappear  quickly  by  the  use  of  emplastrum  hydrargyri,  the 
patient  being  meanwhile  treated  constitutionally  by  one  or  other  of  the 
methods  already  described.  The  plaster  should  be  renewed  every  night;  it 
may  be  usefully  employed  also  in  cases  of  skin  eruptions  elsewhere. 

Condylomata  and  mucous  patches  also  disappear  very  rapidly  where 
local  treatment  is  combined  with  the  internal  administration  of  mercury. 
They  should  be  washed  night  and  morning,  dried  and  dusted  over  with 
a  powder  consisting  of  one  part  of  calomel  and  three  parts  of  starch. 

Tertiary  Syphilis — (a)  General  treatment.  During  this  stage  the 
lesions  will  be  removed  much  more  rapidly  by  means  of  iodide  of  potassium 
than  by  mercury.  We  usually  begin  with  fifteen  grains  of  the  iodide  of 
potassium  three  times  a  day,  and  if  this  does  not  suffice  to  influence  the 
lesions  rapidly,  the  dose  may  be  increased  up  to  thirty  or  forty  grains.  The 
iodide  should  be  taken  from  half  an  hour  to  an  hour  after  meals,  and  it  is 
well  to  give  it  with  tincture  of  orange  peel  or  syrup  of  cinchona  in  order 
to  avoid  griping.  Some  patients  cannot  take  iodide  of  potassium ;  and  if 
it  be  administered  they  at  once  suffer  severely  from  coryza,  pustular  eruptions 
on  the  skin,  pains  in  the  bones,  etc.  In  such  cases  the  sodium  or  strontium 
salt  may  be  substituted  for  that  of  potassium,  but  if  these  cannot  be  borne 
resort  must  immediately  be  had  to  mercurial  inunction  or  intra-muscular 
injections.  It  is  a  curious  fact  that  patients  suffer  less  from  the  physiological 
action  of  iodide  of  potassium  in  large  than  in  small  doses,  and,  before  giving 
up  the  drug  entirely,  one  or  two  large  doses  at  any  rate  should  be  tried. 

In  ordering  iodide  of  potassium  for  tertiary  syphilis  it  must  be  remembered 
that  its  action  is  only  to  cause  disappearance  of  the  syphilitic  lesions  and 
that  it  has  no  permanent  curative  effect.  In  most  cases,  therefore,  it  is  well, 
especially  in  syphilis  of  important  organs,  such  as  the  brain,  the  liver,  etc., 
to  give  the  patient  a  mercurial  course,  either  by  the  mouth  or  by  inunction, 
at  the  same  time  that  he  is  being  treated  with  the  iodide  of  potassium. 
After  the  gums  have  become  affected  the  mercury  may  be  given  up. 

(b}  Local  treatment.     As  in  the  secondary  lesions,  the  local  application 


236  SYPHILIS. 

of  mercury,  especially  in  the  form  of  emplastrum  hydrargyri,  is  often  very 
beneficial  in  the  tertiary  period.  In  very  obstinate  cases,  and  particularly 
in  tertiary  bone  lesions,  much  advantage  may  be  gained  by  excising  and 
scraping  away  the  gummatous  material  in  the  same  way  as  tuberculous 
tissue  is  treated,  but  in  most  instances  the  lesions  rapidly  disappear  when 
iodide  of  potassium  and  mercury  are  administered.1 

Sulphur  Baths  and  Spas  are  much  in  vogue  in  the  treatment  of  syphilis, 
and  a  visit  to  one  or  other  of  them,  more  particularly  Aix-la-Chapelle,  is 
very  much  in  fashion.  These  waters  however  have  no  specific  effect  on 
syphilis,  and  the  benefit  derived  from  a  visit  to  Aix  is  due  essentially  to 
the  careful  antisyphilitic  treatment  carried  out  there  by  the  medical  men, 
and  to  the  fact  that  the  patient  gives  himself  up  entirely  to  the  treatment. 
No  doubt  the  hot  baths  help  the  action  of  the  antisyphilitic  remedies  to 
a  certain  extent,  and  some  of  the  benefit  is  also  due  to  the  complete  rest 
and  absence  of  worry.  It  is  a  very  good  thing  to  send  a  nervous,  over- 
worked business  man  with  an  obstinate  syphilitic  affection  to  Aix,  Wildbad 
or  some  similar  place,  but,  in  the  case  of  patients  of  moderate  or  limited 
means,  it  would  be  wrong  to  put  them  to  the  expense  of  going  there,  seeing 
that  there  is  no  specific  advantage  to  be  derived.  The  best  time  for  a 
visit  to  Aix-la-Chapelle  is  May  or  June  but  it  is  open  all  the  year  round. 

HEREDITARY   SYPHILIS. 

In  inherited  syphilis  where  the  child  is  born  alive  and  apparently  healthy, 
the  lesions  are  very  much  the  same  as  the  secondary  and  tertiary  ones  in 
the  acquired  form,  but  they  are  apt  to  be  more  mixed  in  character,  and 
tertiary  lesions  may  occur  quite  early. 

Treatment. — The  treatment  of  hereditary  syphilis  is  essentially  the  same 
as  that  of  the  acquired  form,  namely,  the  use  of  mercury  in  the  early  lesions, 
and  of  iodide  of  potassium,  with  or  without  mercury,  in  the  later  forms. 
Mercury  is  best  administered  to  infants  by  means  of  inunction,  as  by  this 
means  irritation  of  the  stomach  and  interference  with  the  feeding  of  the 
child  are  entirely  avoided.  One  of  the  most  convenient  ways  is  to  spread 
some  unguentum  hydrargyri  (a  piece  about  the  size  of  a  small  hazel  nut) 
upon  the  binder,  leaving  it  to  the  natural  wriggling  movements  of  the  child 
to  rub  the  mercury  thoroughly  into  the  skin.  The  binder  is  removed 
every  day,  the  skin  well  washed,  and  fresh  ointment  applied.  Should  there 
be  any  irritation  of  the  skin,  a  small  quantity  (about  ten  grains)  of  the 
10  per  cent,  oleate  of  mercury  can  be  rubbed  into  the  legs  and  arms 
in  place  of  the  abdominal  inunction.  As  soon  as  the  symptoms  begin  to 
improve,  the  quantity  used  should  be  diminished,  but  mercurial  treatment 
should  be  gone  on  with,  either  in  the  form  of  mild  inunctions  or  by  internal 
administration,  at  any  rate  for  the  first  year  after  birth.  If  internal  adminis- 
tration of  mercury  be  preferred,  £th  of  a  grain  of  hydrarg.  cum  cret.,  or  T^th 
*See  Brit.  Med.  Journ.,  1897,  Vol.  2,  p.  1571. 


HEREDITARY   SYPHILIS. 


237 


of  a  grain  of  bichloride  of  mercury  well  diluted  may  be  given  three  or  four 
times  a  day.  The  hydrarg.  cum  cret.  may  usefully  be  combined  with 
bicarbonate  of  soda  in  the  proportion  of  one  grain  of  the  former  to  five 
of  the  latter;  one  grain  of  this  is  given  three  or  four  times  a  day  to  an 
infant.  The  bichloride  of  mercury  may  be  given  in  the  form  of  liq. 
hydrag.  perchlor.  flavoured  with  aq.  anethi  or  aq.  chloroformi.  At  the 
same  time  it  is  of  the  greatest  importance  to  attend  to  the  proper  feeding 
of  the  child. 

In  prescribing  iodide  of  potassium,  the  dose  will  vary  with  the  child's 
age.  Dr.  Lauder  Brunton's  plan  of  calculating  the  dose  for  different  ages 
is  very  simple  and  efficacious.  He  takes  the  age  for  the  full  adult  dose 
as  25,  and  reckons  the  age  of  the  child  at  its  next  birthday  as  an  integral 
part  of  that  number ;  the  full  adult  age  is  used  as  the  denominator,  and 
the  child's  age  thus  reckoned  is  used  as  the  numerator.  Thus,  the  dose  for 
a  child  in  the  first  year  of  life  would  be  ^-th  of  the  adult  dose,  that  for  a 
child  one  year  old,  ^-ths  of  the  adult  dose,  and  so  on.  Where  the  syphilis 
has  not  appeared,  or  at  any  rate  has  not  been  treated  with  mercury,  in 
infancy,  it  is  well  to  employ  mercurial  inunction  in  addition  to  the  iodide 
of  potassium  which  will  be  required  in  the  later  manifestations  of  the  disease. 


CHAPTER   XIII. 
CHANCROID,   OR  SOFT   SORE. 

Definition. — Chancroid  is  an  infective  ulceration  due  to  a  bacterium, 
and  generally  occurs  on  the  prepuce  or  glans  penis.  The  affection  is 
locally  inoculable,  and  frequently  leads  to  infection  of  the  neighbouring 
glands,  but  general  infection  never  follows. 

Symptoms. — As  the  result  of  infection  there  is  a  local  sore  which  begins 
as  a  pimple  a  few  hours  after  inoculation,  rapidly  enlarges  and  ulcerates, 
and  gives  rise  to  other  sores  in  its  vicinity.  These  extend  rapidly,  and  may 
cause  considerable  loss  of  substance ;  when  on  the  frenum  they  may  perforate 
or  destroy  it;  when  beneath  the  prepuce  they  may  give  rise  to  a  good  deal 
of  oedema  and  phimosis  or  paraphimosis ;  and  where  no  attention  is  paid  to 
cleanliness  they  are  apt  to  lead  to  sloughing  and  a  condition  of  phagedena. 

The  inguinal  glands  very  quickly  become  infected,  and  the  glands 
nearest  the  genitals  enlarge  and  often  suppurate;  suppuration  may  occur 
in  one  gland  after  another,  so  that  the  affection  may  be  a  long  and  tedious 
one.  When  these  abscesses  are  opened  or  burst  spontaneously,  the  skin  is 
frequently  found  to  be  undermined  for  a  considerable  distance ;  extensive 
chancroid  ulceration  may  occur  in  the  groin,  which  takes  a  long  time  to 
heal,  and  which  may  cause  widespread  destruction  of  tissue.  The  organism 
causing  the  chancroid  ulceration  is  said  to  be  purely  aerobic ;  a  fact  that  may 
explain  the  extensive  and  rapidly  spreading  ulceration  that  so  often  occurs 
after  these  abscesses  have  burst  or  have  been  simply  incised. 

Treatment. — When  we  bear  in  mind  the  serious  results  that  may  follow 
chancroids,  and  the  length  of  time  that  the  patient  may  be  laid  up  and 
unable  to  follow  his  occupation,  it  is  evidently  very  important  to  endeavour 
to  cut  short  the  disease  at  as  early  a  stage  as  possible. 

Local  Treatment. — Hence,  as  soon  as  the  diagnosis  is  made  (and  the 
chief  point  is  to  distinguish  chancroid  from  herpes  prseputialis  on  the  one 
hand,  and  syphilis  on  the  other),  an  attempt  should  be  made  to  destroy 
the  sore  by  caustics,  of  which  the  best  is  probably  nitric  acid.  In  applying 
caustics  care  must  be  taken  to  prevent  fresh  infection  of  the  surface,  and 
they  should  never  be  employed  unless  the  sores  can  be  readily  exposed. 


CHANCROID,    OR   SOFT   SORE.  239 

(a)  Where  there  is  no  Phimosis. — In  sores  under  the  prepuce  where 
the   latter   is   not   oedematous   and   can    be   readily   retracted,    the   prepuce 
should  be  pulled  back  and  the  whole   exposed   surface   thoroughly  washed 
with    a    1-20   carbolic   lotion   and   subsequently   with   a    1-2000   sublimate, 
especial    attention    being    paid   to    the   thorough   cleansing   of    the    sulcus 
behind   the   corona   glandis.      The   sores   should   then    be    dried   carefully 
and  a  10  per  cent,  solution  of  cocaine  applied  to  their  surfaces.     After  a  few 
minutes  this  is  wiped  off,  and   then   the   nitric   acid   is   applied  either  by 
means  of  a  rod  or  brush  of  glass,  or,  failing  that,  with  a  small  piece  of 
wood,  such  as  a  match.     The  surface  and  edges  of  the  sore  are  thoroughly 
mopped   with   the   acid   and   great   care   must    be  taken  not  to  let  it  run 
over   the   neighbouring   mucous    membrane.       After    allowing   the   acid    to 
soak  into  the  tissues  for  five  minutes  or  so,  any  excess  is  neutralised   by 
plunging  the  end  of  the  penis  into  a  saturated   solution   of  carbonate   of 
soda  till  effervescence  entirely  ceases.     The  parts  should  next  be  thoroughly 
washed     with     warm     sublimate     solution,     and     powdered     thickly     over 
with   iodoform,    outside   which    is   applied    boracic    lint    dipped    in    warm 
boracic   lotion ;    the   prepuce   is    then   pulled   forward   over   the  lint  so  as 
to   keep   it   in   position.      The  prepuce  should  be  retracted  three  or  four 
times   daily,  the   parts   bathed   in   a    warm    1-2000   sublimate  solution,  the 
boracic    lint    carefully   removed   and    at    once    burnt,    and    a    fresh    piece 
applied.      As    the    sores    heal,   the    lint    need    not    be    changed    so    often. 
When  granulation  is  complete,  the  iodoform  and  lint  may  be  abandoned. 
and   %   strength   boracic   ointment   substituted,    until    healing    is    complete. 
The    same    treatment    should    be    adopted    in    cases   where   the   sores   are 
situated  on  the  glans  penis. 

(b]  Where  there  is  Phimosis. — Where  the  prepuce  is  cedematous  and 
cannot  be  retracted,  there  should  be  no  hesitation  in  slitting  it  up   so  as 
to  get  free  access  to  the  sores.      In  the  first  place  an  anaesthetic  is  given. 

O  A  O 

and  the  parts  beneath  the  prepuce  are  syringed  out  as  thoroughly  as  possible 
with  warm  1-2000  sublimate  solution.  The  prepuce  is  then  slit  up  along 
the  middle  line  upon  its  dorsal  surface  so  that  the  glans  can  be  thoroughly 
exposed ;  this  may  be  done  by  thrusting  a  curved  bistoury  beneath  it  or 
by  introducing  one  blade  of  a  pair  of  blunt-pointed  scissors  between  the 
glans  and  the  prepuce.  The  parts  are  thus  fully  exposed  and  are  then 
washed  with  the  strong  mixture,  and  subsequently  with  a  1-2000  sublimate 
solution  and  the  sores  thoroughly  cauterised  in  the  manner  just  described, 
powdered  with  iodoform  and  dressed  with  wet  boracic  lint.  As  the  latter 
very  readily  dries  up,  it  is  as  well  to  put  a  piece  of  guttapercha  tissue 
outside  it  and  to  keep  the  penis  in  a  boracic  bag  (see  p.  230).  Iodoform  is 
objectionable  on  account  of  its  smell,  and,  therefore,  as  soon  as  the 
sore  begins  to  assume  a  healthy  appearance,  its  use  may  be  discontinued. 
Phagedenic  sores  should  also  be  treated  by  cauterisation,  and  especial 
care  must  be  paid  to  cleanliness,  and  if,  as  the  slough  separates,  portions 
of  the  sore  show  fresh  signs  of  infection,  they  should  again  be  destroyed. 


240  CHANCROID,   OR   SOFT   SORE. 

The  cauterisation  may  be  effected  in  the  milder  cases  by  means  of  nitric 
acid ;  if,  however,  the  affection  be  extensive  and  spreading  rapidly,  the 
actual  cautery  may  be  necessary.  The  destruction  of  the  affected  parts  must 
be  carried  out  boldly;  the  best  plan  is  to  put  the  patient  under  an 
anaesthetic,  clip  away  all  sloughs  and  undermined  skin,  and  then  cauterise 
the  whole  area  thoroughly,  going  quite  wide  of  the  disease  both  in  its  super- 
ficial area  and  in  depth  (see  also  p.  59).  The  after-treatment  is  the  same 
as  that  just  described. 

General  Treatment. — The  patient  must  have  nutritious  diet,  and 
should  rest  as  much  as  possible,  so  as  to  avoid  irritation  of  the  inguinal 
glands.  Certainly  all  violent  exercise,  such  as  games,  prolonged  standing, 
bicycling,  etc.,  should  be  strictly  prohibited.  In  the  severer  cases,  rigid 
confinement  to  bed,  with  the  administration  of  quinine  and  diffusible 
stimulants  are  absolutely  necessary.  The  bowels  should  be  kept  acting 
regularly. 

Treatment  of  Inflamed  Glands.— As  soon  as  signs  of  inflammation 
of  the  inguinal  glands  become  evident,  the  patient  should  be  put  to  bed 
and  warm  fomentations  applied  to  the  groins;  if  the  primary  sores 
are  doing  well,  it  not  uncommonly  happens  that  the  glandular  inflammation 
subsides.  We  do  not  advise  the  peri-  and  intra-glandular  injection  of 
carbolic  acid  and  other  substances  advocated  by  some  surgeons,  as  they 
are  painful  and  generally  inefficient.  Most  careful  watch  should  however 
be  kept  and,  if  it  become  evident  that  suppuration  is  occurring,  excision 
of  the  mass  of  glands  and  the  abscess  in  them  should  be  at  once  resorted 
to.  By  this  means  much  time  is  saved,  and  a  long  illness  avoided,  for 
if  these  abscesses  are  once  allowed  to  open  spontaneously,  the  surface 
may  become  chancroid  and  healing  is  then  very  slow  and  is  often  further 
delayed  by  the  formation  of  fresh  abscesses  in  the  neighbouring  glands. 
This  can  be  avoided  by  making,  in  the  first  instance,  a  clean  sweep  of 
the  affected  glands  and  the  neighbouring  tissues.  It  is  not  sufficient  to 
simply  shell  out  the  enlarged  glands,  because  the  peri-glandular  tissue 
very  soon  becomes  affected  and  suppuration  may  occur  in  it.  Care 
should  also  be  taken  to  cut  wide  of  any  abscess  that  may  have  already 
formed. 

After  the  skin  has  been  thoroughly  shaved  and  disinfected,  a  free 
incision  is  made  over  the  mass,  and  then  the  knife  is  carried  through  the 
healthy  fat  at  some  distance  from  the  glands  and,  after  a  little  dissection, 
the  whole  mass  is  lifted  out;  should  the  skin  be  adherent,  the  infiltrated 
area  is  enclosed  in  an  oval  incision  and  removed  with  the  glands.  After 
an  operation  of  this  kind  it  is  well  to  insert  a  drainage  tube  at  the  outer 
angle  of  the  wound  and  to  retain  it  for  a  few  days  in  case  any  infection 
of  the  operation-wound  has  occurred. 

Sometimes,  however,  the  case  is  not  seen  until  a  large  abscess  is  present, 
and  then  the  surgeon  must  content  himself  with  making  a  small  opening 
into  it,  inserting  through  this  a  small  sharp  spoon,  scraping  the  wall  of  the 


CHANCROID   OR  SOFT  SORE. 


241 


cavity  thoroughly,  and  washing  it  out.  Some  iodoform  emulsion  (see  p.  249) 
should  be  injected  and  a  small  strand  of  horsehair  or  a  shred  of  gauze 
laid  between  the  edges  of  the  wound,  so  as  to  allow  of  the  escape  of  the 
discharge,  and  then  outside  the  first  few  layers  of  the  cyanide  gauze  dressing, 
firm  pressure  is  made,  either  by  sponges  or  a  pad  of  gauze  or  salicylic  wool 
kept  in  place  by  a  spica  bandage  reinforced  by  elastic  webbing  (see  p.  1 70) ; 
this  obliterates  the  abscess  cavity  by  bringing  its  walls  well  into  contact 
everywhere.  This  is  important,  since  the  organism  being  aerobic,  it  is  thus 
deprived  of  its  due  supply  of  air  much  more  effectually  than  if  a  drainage 
tube  were  inserted ;  its  growth  is  therefore  much  more  readily  brought  to  a 
stand  still.  Great  care  must  be  taken  in  the  antiseptic  management  of  these 
cases,  and  the  drain  must  not  be  left  out  until  suppuration  has  entirely  ceased. 
Where  the  abscess  has  burst  and  a  chancroid  surface  is  left,  the  skin 
around  must  be  purified  and  the  surface  of  the  sore  cauterised  with  nitric 
acid  in  a  manner  similar  to  that  described  for  the  primary  sore.  Afterwards 
cyanide  gauze  dressings  and  wool  should  be  used  until  the  ulcer  has  become 
healthy  and  superficial,  when  weak  boracic  ointment  may  be  substituted. 


CHAPTER   XIV. 
TUBERCULOSIS. 

Definition. — Tuberculosis  is  an  infective  disease,  due  to  the  growth  of 
the  tubercle  bacillus  in  the  tissues,  which  is  characterised  by  the  formation 
of  nodules  or  tubercles  tending  to  run  together,  break  down  and  caseate,  and 
to  destroy  the  structures  in  which  they  are  situated. 

Seats. — The  most  frequent  seat  of  tuberculosis  is,  perhaps,  the  lym- 
phatic glands,  more  particularly  those  of  the  cervical,  bronchial,  and 
mesenteric  regions.  Another  very  common  seat  of  the  affection  is  the  peri- 
osteum and  the  cancellous  tissue  at  the  ends  of  bones.  Tuberculous  lesions 
are  also  very  frequently  met  with  in  the  synovial  membranes  and  in  serous 
membranes  in  general,  such  as  the  peritoneum,  the  pleura,  and  the  sheaths 
of  tendons.  They  may  also  occur  in  various  internal  organs,  such  as  the 
lungs,  the  kidneys,  the  prostate,  etc.  In  fact,  we  may  find  a  tuberculous 
lesion  wherever  there  is  connective  tissue  and  a  suitable  spot  for  the  growth 
of  the  bacillus  after  it  has  gained  access  to  the  body. 

Accessory  Factors. — -Although  the  tubercle  bacillus  is  the  essential 
cause  of  tuberculosis,  a  number  of  accessory  factors  of  great  importance 
are  concerned  in  the  production  of  the  disease ;  without  their  concurrence 
the  affection,  in  many  cases,  would  not  occur.  These  accessory  causes  may 
be  local  or  general. 

(a)  Local.— Among  local  factors  injury  plays  an  important  part  as  a 
predisposing,  and,  sometimes,  as  an  exciting  cause  of  the  tuberculous  lesions  • 
this  is  most  frequently  the  case  in  tuberculosis  of  bones  and  joints.  It  is 
important  to  note  that  the  injury  must  be  a  mild  one;  a  severe  one,  such 
as  a  fracture,  does  not  usually  lead  to  the  deposit  of  tubercle  in  the  damaged 
part,  probably  because  the  processes  of  repair  are  then  so  active  that  the 
bacillus  cannot  cope  with  them.  A  slight  injury,  on  the  other  hand, 
particularly  one  in  the  nature  of  a  sprain,  weakens  the  tissues  without 
leading  to  any  marked  cell-exudation,  and  the  bacilli  then  seem  able  to 
obtain  a  good  footing  in  them.  Exposure  to  cold  probably  also  acts  in  this 
way,  and,  where  the  bacilli  are  already  present  in  the  body,  it  leads  to  their 
deposit  in  the  part  subjected  to  the  action  of  the  cold.  Indeed,  anything 


TUBERCULOSIS. 


243 


which  lowers  the  vitality  and  resistance  of  the  tissues  predisposes  them  to 
the  attack  of  the  tubercle  bacillus. 

Sepsis  is  also  very  important,  not  so  much  as  an  inducing  cause  as  one 
which  increases  the  activity  of  the  disease,  or  at  any  rate  interferes  with 
its  spontaneous  cure.  Chronic  inflammation  of  a  tissue  seems  to  weaken 
it  and  to  enable  the  bacilli  to  obtain  a  foothold,  and  to  spread  more  rapidly 
than  in  healthy  parts,  and  anything  which  keeps  up  a  state  of  chronic 
inflammation  may  favour  the  development  of  tubercle  in  persons  in  whose 
bodies  the  bacilli  are  present. 

There  are  also  certain  conditions  connected  with  the  bacilli  themselves 
which  are  of  great  importance,  the  principal  being  the  number  of  the 
organisms  that  gain  entrance  to  the  part.  When  the  bacilli  are  few  in 
number  the  risk  of  infection  is  not  great,  and  if  it  does  occur,  the  disease 
is  generally  more  chronic  than  when  they  are  numerous.  The  bacilli  also 
vary  much  in  virulence  under  different  conditions,  and  lastly,  the  result 
depends  a  good  deal  upon  whether  they  are  free  or  are  attached  to  coarser 
particles.  Where  bacilli  are  isolated  and  are  present  only  in  small  numbers, 
they  sometimes  pass  through  the  mucous  membranes  and  become  caught 
in  the  neighbouring  lymphatic  glands  without  giving  rise  to  any  primary 
disease  at  the  seat  of  entrance ;  this  is  more  especially  the  case  in  the 
intestinal  tract  and  the  lungs.  Where,  however,  they  are  attached  to  coarser 
particles,  for  example,  where  the  source  from  which  the  infection  is  derived 
is  cheesy  material  which  is  not  broken  up  very  fine,  then  there  is  a  local 
tuberculosis  at  the  point  of  entrance,  and  from  this  the  glandular  infection 
may  subsequently  result. 

(b]  General.— The  question  of  heredity  is  one  of  the  first  for  consider- 
ation, and  it  is  held  by  many  that  tuberculosis  is  an  hereditary  disease.  As 
a  matter  of  fact,  however,  there  is  no  evidence  of  this  heredity  per  se ; 
what  seems  to  be  inherited  is  the  tendency  of  the  tissues  to  form  a  good 
nidus  for  the  growth  of  the  tubercle  bacillus.  This  tendency  may  also 
be  induced  by  such  conditions  as  bad  hygiene,  confinement  in  close  rooms, 
foul  air,  etc. ;  according  to  others,  the  same  result  is  produced  by  the 
ingestions  of  foods  rich  in  potash  and  deficient  in  sodium,  such  as  an 
excessive  amount  of  vegetables,  especially  potatoes. 

Other  factors  which  appear  to  exercise  an  important  influence  on  the 
development  of  tuberculosis,  although  we  cannot  exactly  say  in  what  way 
they  are  exerted,  are  age  and  sex.  Surgical  tuberculous  diseases  occur 
most  commonly  in  children  before  the  age  of  ten,  but  they  also  occur 
up  to  old  age,  and  from  the  point  of  view  of  treatment,  it  is  important 
to  note  that,  the  older  the  patient,  the  less  is  the  likelihood  of  a  spontaneous 
cure.  Sex  has  also  a  considerable  influence  in  so  far  as  females  do  not 
seem  to  be  so  predisposed  to  certain  forms  of  tuberculosis  as  are  males. 
This  applies  more  particularly  to  the  affections  of  bones  and  joints,  and 
although  to  some  extent  this  may  be  explained  by  the  greater  exposure 
of  the  male  to  injury,  this  consideration  does  not  entirely  meet  the  facts. 


244 


TUBERCULOSIS. 


Climatic  conditions  are  very  important  as  accessory  factors.  In  climates 
where  individuals  are  much  exposed  to  cold  and  wet,  and  where,  moreover, 
they  congregate  in  small  over-heated  rooms,  the  disease  is  very  apt  to 
occur,  especially  if  one  of  the  community  has  tuberculosis  and  thus  forms 
a  focus  of  infection  for  the  rest. 

Pathology. — The  bacillus  when  introduced  into  the  tissues  leads  to 
the  formation  of  a  microscopic  collection  of  cells,  termed  a  tubercle.  These 
cells  are  epitheloid  cells,  which  are  much  larger  than  the  ordinary  white 
corpuscles,  and  are  probably  derived  from  pre-existing  connective-tissue 
cells,  from  the  lymphatic  endothelium,  or  even  sometimes  from  the  endo- 
thelium  of  the  blood-vessels.  Among  these  epitheloid  cells  one  or  more 
in  each  tubercle  very  often  increase  in  size  or  run  together,  and  form  what 
are  called  giant  cells.  The  subsequent  history  is  that  these  tubercles 
increase  in  number  until  a  large  mass  is  formed ;  caseation  then  commences 
in  the  older  tubercles,  the  cells  gradually  die,  and  the  result  is  that  to- 
wards the  centre,  or  at  any  rate  towards  the  older  part  of  the  mass,  a  cheesy 
material  is  formed ;  this  may  become  encapsuled  and  remain  quiescent, 
or  it  may  give  rise  to  a  chronic  abscess.  Around  the  tubercles  there 
is  generally  a  considerable  area  which  is  not  yet  infected  with  the  bacillus 
but  which  is  in  a  state  of  chronic  inflammation  ;  this  chronic  inflammation 
is  of  great  importance  as  an  aid  to  the  spread  of  the  tubercles,  as  the 
latter  more  readily  invade  any  structure  thus  affected  than  one  that  is 
quite  healthy. 

Retrogressive  Changes. — The  resistance  of  the  living  tissues  to  the 
growth  of  the  organism  is  very  considerable,  so  that  in  many  cases,  when 
the  causes  which  facilitate  the  progress  of  the  disease  are  removed,  the 
bacillus  is  destroyed  or  gradually  ceases  to  grow,  and  retrogressive  changes 
then  take  place.  These  latter  consist  essentially  in  the  conversion  of 
the  tubercle  into  fibrous  tissue  and  the  ultimate  disappearance  of  the 
tuberculous  material.  In  other  cases,  where  the  tuberculous  tissue  has  under- 
gone caseation  and  recovery  takes  place,  portions  of  the  cheesy  material  are 
absorbed  whilst  others  are  left  behind  and  become  encapsuled  and,  for  the 
time  being,  quiescent,  but  unfortunately  the  bacilli  or  their  spores  seem  to 
retain  their  vitality  in  these  masses  for  an  indefinite  period.  As  long  as  the 
capsule  around  the  caseous  material  is  unbroken,  and  the  latter  is  pro- 
tected from  the  action  of  the  cells  and  juices  of  the  tissues,  the  bacilli 
seem  to  lie  dormant,  but  any  slight  injury  or  some  constitutional  cause 
may  very  rapidly  break  up  this  encapsuled  mass  and  lead  to  fresh  growth 
of  the  organism  and  fresh  infection  of  the  part.  It  is,  however,  very 
important  to  remember  that,  where  the  conditions  are  favourable,  the  body 
has  a  very  strong  tendency  to  check  the  growth  of  the  bacillus  or  even  to 
overcome  it  altogether. 

Causes  inimical  to  them. — Various  causes  prevent  the  living  tissues 
from  destroying  the  tubercle,  and  these  influences  must  be  borne  in 
mind  so  that,  if  present,  they  may  be  neutralised  or  removed.  The  majority 


TUBERCULOSIS.  245 

of  them  have  already  been  mentioned ;  they  are  the  conditions  of  the 
tissues  which  facilitate  the  growth  of  the  bacilli,  such  as  those  produced 
by  heredity  or  induced  by  food  ;  careful  attention  to  diet  is  therefore  a 
very  important  point  in  treatment.  Injuries  not  only  predispose  the 
tissues  to  the  deposit  of  tubercles  in  the  damaged  part,  but  are  also 
likely  to  increase  the  virulence  of  the  disease  when  present.  Cold,  sepsis, 
etc.,  also  act  similarly,  and  further,  the  influence  of  climate  and  hygienic 
conditions  are  points  of  great  importance.  The  relation  of  tuberculosis  to 
other  diseases  is  also  of  interest,  for  the  occurrence  of  the  latter  in 
tuberculous  patients  is  very  apt  to  light  up  the  disease  or  to  encourage  its 
spread.  This  is  especially  the  case  with  regard  to  influenza,  measles, 
chicken-pox,  etc.,  and  as  far  as  possible,  therefore,  exposure  to  these 
diseases  should  be  avoided. 

Treatment- — In  dealing  with  tuberculous  diseases  we  can  of  course 
only  speak  here  of  the  General  Treatment.  The  local  treatment  must 
be  considered  in  connection  with  the  parts  affected,  and  will  be 
described  when  we  come  to  deal  with  the  various  regions  that  may  be 
the  seat  of  the  disease.  Roughly  speaking,  we  may  say  that  the  general 
treatment  of  tuberculous  disease  has  two  aims,  viz. :  (i)  to  place  the  body 
in  a  better  condition  to  resist  the  progress  of  the  disease,  and  (2)  to  act 
directly  on  the  tuberculous  process.  The  methods  of  treatment  directed 
to  the  latter  end  consist  essentially  of  various  forms  of  operations,  and  the 
use  of  various  substances  supposed  to  exert  a  destructive  action  on  the 
tubercle  bacillus,  for  example  Koch's  tuberculin,  iodoform,  benzoate  of  soda 
and  many  others.  These  latter  methods  have  more  or  less  failed  in  their 
object,  so  that  we  cannot  recommend  them,  while  the  operative  and  other 
local  measures  will  be  discussed  in  connection  with  the  parts  affected. 

On  the  other  hand,  there  are  a  variety  of  methods  of  general  treatment 
which  may  be  employed  to  increase  the  resisting  power  of  the  tissues,  or 
to  remove  the  causes  which  favour  the  growth  of  the  bacillus,  and  these 
may  be  indicated  here.  An  essential  point  is  to  put  the  patient  under  the 
best  possible  hygienic  conditions.  A  tuberculous  subject  must  be  kept 
from  exposure  to  cold  and  wet,  which  may  not  only  induce  tuberculosis  in 
some  part  of  the  body  not  yet  affected,  but  may  also  exaggerate  an  already 
existing  lesion.  He  must  have  the  maximum  amount  of  fresh  air  and 
sunshine  possible,  and  therefore  it  is  very  important  that  he  should 
be  sent  where  he  can  live  a  healthy  out-door  life.  There  is  however  no 
special  climate  suitable  for  all  tuberculous  cases.  Some  do  better  in  a 
cold  and  bracing  climate,  others  in  a  warm  one,  provided  it  be  not  relaxing. 
Hence  all  patients  should  not  be  sent  to  the  same  place,  or  to  the  same 
sort  of  climate ;  it  is  necessary  to  ascertain  which  suits  the  individual  best. 
The  only  requisite  that  should  be  looked  upon  as  a  sine  qua  non  is  that 
the  place  selected  should  be  one  where  it  is  possible  to  practically  be  out 
of  doors  all  day  without  danger  of  taking  cold.  When  the  lower  extremities 
are  unaffected  care  should  be  taken  to  secure  a  sufficient  amount  of 


246  TUBERCULOSIS. 

exercise ;  the  particular  form  should  be  such  that  the  patient  runs  no  risk 
of  injury,  for  a  local  deposit  of  tubercle  is  likely  to  occur  at  any  spot 
injured.  The  question  of  diet  is  also  of  importance ;  it  should  be 
nourishing  and  easily  digestible,  and  the  amount  of  vegetables,  in  particular 
the  consumption  of  potatoes,  should  be  limited. 

Among  drugs  there  are  no  specifics  against  tuberculosis.  The  only 
point  of  importance  with  regard  to  them  is  that  only  those  should  be 
ordered  which  will  increase  the  nutrition  of  the  body.  Of  these  the  best 
seems  to  be  cod  liver  oil  which  may  be  given  pure  or  in  the  form  of  one 
of  the  more  tasteless  emulsions,  such  as  Scott's,  Mellin's  or  M'Kenzie's. 
As  much  of  the  drug  should  be  given  as  is  possible  without  disordering 
the  digestion.  As  a  rule  it  is  well  to  begin  with  teaspoonful  doses  three 
or  four  times  a  day,  and  to  increase  it  until  it  is  found  that  the  patient  will 
not  bear  any  more:  cod  liver  oil  should  be  given,  however  well-nourished  or 
healthy  the  patient  may  seem  to  be.  Children  as  a  rule  take  the  emulsions 
without  any  trouble.  Where  pure  cod  liver  oil  is  used  it  is  probably  best  to 
float  it  on  milk.  In  connection  with  the  administration  of  cod  liver  oil  a 
method  suggested  by  Mr.  Edmund  Owen  for  administering  it  to  children 
who  resent  taking  the  oil  as  ordinarily  prescribed,  will  sometimes  be  found 
of  use.  It  consists  in  replacing  the  ordinary  cottonseed  oil,  in  which 
sardines  are  preserved,  by  cod  liver  oil  (a  tasteless  variety  for  choice)  and 
serving  it  on  the  plate  with  the  fish.  The  tin  is  filled  up  from  time  to 
time  with  the  oil,  and  children  who  are  fond  of  sardines  will  often  take 
large  quantities  in  this  manner  without  demur.  The  drug  is  apt  to  disagree 
with  people  during  warm  weather,  and  the  general  rule  is  that  it  should  be 
intermitted  during  the  summer;  cream,  fat  bacon,  olive  oil,  etc.,  should  be 
substituted. 

A  drug  that  is  very  fashionable  in  tuberculosis,  although  it  is  questionable 
whether  it  does  any  good,  is  syrup  of  the  iodide  of  iron,  given  in  doses  of 
from  15  to  25  minims  three  times  a  day,  mixed  with  water  or  milk.  Among 
other  drugs,  the  use  of  iron,  either  in  the  form  of  tincture  of  perchloride  of 
iron  in  10  or  i5-minim  doses,  or  as  Blaud's  preparation  in  doses  of  from  3 
to  10  grains,  according  to  the  age  of  the  patient,  are  of  value.  Tincture  of 
nux  vomica  is  very  useful  where  the  appetite  is  bad ;  in  fact  anything  that  will 
increase  the  general  nutrition  of  the  patient  may  with  advantage  be 
administered.  Guaiacol  in  doses  of  i  to  5  minims  is  a  drug  which  is  much 
in  vogue  at  the  present  time  and  which  seems  to  be  really  of  service. 

When  exercise  cannot  be  obtained,  as  may  happen  when  the  situation 
of  the  disease  demands  absolute  rest  in  bed,  much  benefit  may  be  obtained 
by  general  massage.  This  for  example  may  be  usefully  applied  to  the 
extremities  when  the  spine  is  the  seat  of  the  disease,  or  to  the  upper 
extremity  or  the  trunk  when  the  lower  limbs  are  affected,  and  in  this  way 
a  considerable  amount  of  exercise  can  be  obtained ;  it  should  be  combined 
with  plenty  of  fresh  air,  which  may  be  obtained  by  wheeling  the  patient 
out  on  a  couch.  By  these  means  both  the  appetite  and  the  general  nutri- 


CHRONIC   ABSCESS.  247 

tion  can  be  well  sustained.  Steps  must  also  be  taken  to  diminish  the 
amount  of  inflammation  about  the  affected  part,  and  where  this  is  done  the 
tendency  to  cure  is  greatly  aided.  The  first  essential  point  in  this  part 
of  the  treatment  is  absolute  rest,  whether  the  cause  of  unrest  comes  from 
without  or  within,  for,  apart  from  the  presence  of  the  tuberculous  disease, 
movement  promotes  the  inflammatory  condition.  When  we  come  to  deal 
with  joints  we  shall  have  to  lay  stress  upon  another  condition  which  must 
be  attended  to,  namely,  the  tonic  contraction  of  the  muscles  in  the  neigh- 
bourhood of  the  diseased  joint,  which  leads  to  pressure  of  the  inflamed 
articular  surfaces  against  each  other.  Here,  therefore,  rest  must  be  com- 
bined with  extension,  so  as  to  tire  out  the  muscles  and  prevent  the  violent 
pressure  of  the  two  surfaces  against  one  another. 

Various  other  methods  may  be  employed  to  remove  the  chronic  inflam- 
mation ;  these  have  already  been  referred  to  in  full  in  speaking  of  chronic 
inflammation  generally  (see  p.  17).  The  actual  cautery,  for  example,  is  of 
great  value  in  many  cases  of  deep-seated  bone  and  joint  disease,  such  as 
disease  of  the  spine,  the  hip  or  the  shoulder  joint.  Pressure  is  also  of 
use  either  combined  with  counter-irritation,  as  by  Scott's  dressing  (see 
p.  21),  or  alone  as  by  wrapping  the  joint  in  a  large  mass  of  wool  and  then 
applying  a  firm  bandage  over  it,  the  bandage  being  prevented  from  slipping 
by  rubbing  into  it  a  solution  of  starch  or  silicate.  It  is  not  necessary  here 
to  repeat  the  various  measures  for  combating  chronic  inflammation  ;  they 
are  fully  referred  to  in  Chapter  I. 


CHRONIC   ABSCESS. 

Before  leaving  the  general  consideration  of  tuberculous  diseases,  we 
may  discuss  at  greater  length  the  question  of  chronic  abscess,  which  is 
only  another  name  for  one  of  a  tuberculous  nature.  In  this  condition 
an  abscess  forms  without  any  of  the  cardinal  symptoms  of  inflammation 
except  the  swelling.  Pain  may  be  absent  or  very  slight,  there  is  not 
necessarily  any  increase  of  the  body  temperature,  though  locally  the  affected 
area  may  feel  a  little  warmer  than  the  surrounding  parts,  and  there  is 
no  redness  of  the  skin  over  the  seat  of  the  disease,  unless  the  skin  itself 
be  actually  involved.  The  swelling  is  caused  by  the  presence  of  fluid 
and  differs  entirely  from  the  brawny  swelling  that  is  met  with  in  acute 
abscesses.  In  fact  the  chronic  abscess  is,  in  the  great  majority  of  cases, 
simply  a  softening  tuberculous  deposit. 

Briefly,  the  history  of  a  chronic  abscess  of  the  subcutaneous  tissue 
is  that  it  begins  as  a  small  tuberculous  nodule  which  gradually  increases 
in  size,  undergoes  caseation  and  softens  in  the  centre.  When  this  occurs 
the  inflammation  around  becomes  a  little  more  active,  and  there  is  an 
effusion  of  fluid  along  with  a  considerable  number  of  leucocytes  into  the 
cheesy  material ;  the  result  being  an  investing  layer  of  tuberculous  tissue 


248  TUBERCULOSIS. 

containing  fluid  mixed  with  broken  down  cheesy  material,  disintegrated 
tissues  and  leucocytes.  The  essential  part  of  a  chronic  abscess  is  the 
wall,  and  to  it  any  curative  treatment  must  be  particularly  directed.  The 
mere  evacuation  of  its  contents  will  not,  as  in  an  acute  abscess,  necessarily 
lead  to  a  subsidence  of  the  disease.  The  tubercle  bacilli  and  the  tubercles 
themselves  are  present  in  the  wall,  and  all  that  is  evacuated  when  the 
abscess  is  incised  are  the  broken  down  contents,  along  with  the  fluid  and 
leucocytes  that  have  passed  into  it  as  the  result  of  the  inflammation  around. 
Treatment. — The  aim  of  the  treatment  must,  therefore,  be  to  deal 
with  the  wall  of  the  abscess,  and  this  is  carried  out  in  various  ways  according 
to  its  situation  and  extent. 

Excision. — Where  the  abscess  is  only  quite  small  and  subcutaneous, 
the  simplest  plan  of  treatment  is  to  excise  the  abscess  wall  with  its  contents 
intact,  as  if  it  were  a  sebaceous  cyst.  Similarly,  where  the  abscess  is 
connected  with  a  gland,  and  even  when  it  has  perforated  the  gland  capsule 
and  spread  through  the  fascia  to  the  subcutaneous  tissue,  the  only  satisfactory 
treatment  is  to  dissect  out  the  wall  of  the  abscess,  and  along  with  it,  the 
gland  from  which  it  comes.  This  may  be  looked  upon  as  the  ideal  treat- 
ment of  a  chronic  abscess :  to  dissect  away  completely  and  cleanly  the 
wall,  and  the  focus  from  which  it  originates.  Moreover,  if  the  abscess  be 
pointing,  and  has  led  to  thinning  and  infection  of  the  skin,  the  affected 
portion  of  the  skin  should  also  be  removed.  Any  attempt  to  save  it  will 
leave  tuberculous  material  behind,  and  this  may  act  as  a  focus  for  the 
re-infection  of  the  wound,  so  that  healing  may  be  delayed ;  the  thin  skin 
if  left  will  not  recover,  and  its  death  will  lead  to  an  ugly  scar.  Hence  all 
adherent  skin  should  be  excised,  and  unless  a  large  area  be  affected  there 
is  no  difficulty  in  bringing  the  edges  of  the  wound  together  after  under- 
mining the  tissues  around.  When  an  abscess  has  been  dissected  out  in 
this  way,  the  wound  can  be  stitched  up  completely  and  treated  in  the 
manner  recommended  for  the  treatment  of  aseptic  incised  wounds  (see 
p.  152).  Should  the  abscess  wall  burst  during  the  course  of  dissection, 
and  pus  escape  into  the  wound,  the  latter  should  be  thoroughly  and  fre- 
quently douched  out  during  the  remainder  of  the  operation ;  curiously 
enough,  under  these  circumstances  tuberculous  infection  of  the  wound  does 
not  as  a  rule  occur.  Where  the  abscess  is  connected  with  a  gland,  it  is 
not  sufficient  to  remove  the  gland  which  has  led  to  the  abscess ;  any  others 
in  the  neighbourhood  which  are  enlarged  should  also  be  taken  away. 

Partial  Removal  of  Abscess  Wall. — In  very  large  deep-seated  chronic 
abscesses  it  is  of  course  impossible  to  remove  the  wall  completely.  Here,  one 
of  two  procedures  may  be  adopted.  In  the  first  place,  if  the  abscess  be 
situated  so  deeply  that  it  cannot  be  dissected  away,  and  if  no  important 
structures  intervene  between  the  abscess  wall  and  the  surface,  the  former 
should  be  laid  freely  open  (unless  it  be  very  important  to  avoid  causing  a 
scar),  so  that  the  whole  interior  of  the  abscess  cavity  is  exposed  to  view; 
as  much  of  the  wall  as  possible  should  then  be  dissected  out  and  clipped 


CHRONIC   ABSCESS.  249 

away  with  scissors.  Any  portions  of  wall  that  cannot  be  treated  in  this 
manner  must  be  thoroughly  scraped.  The  best  instrument  to  use  for  this 
purpose  is  Barker's  flushing  spoon  (see  Fig.  55),  by  means  of  which  a 
constant  stream  of  fluid  is  kept  flowing  over  the  parts,  so  that  the  material 
loosened  by  the  spoon  is  at  once  carried  away  and  does  not  lodge  in  the 
recesses  of  the  wound.  The  fluid  used  for  this  irrigation  should  be  warm 
1-4000  perchloride  of  mercury,  and  when  the  part  has  been  thoroughly 
scraped  out  and  the  wound  completely  cleansed  from  all  flakes  of  cheesy 
material  and  pus,  a  little  iodoform  and  glycerine  in  the  form  of  a  10  per 
cent,  emulsion,  made  by  adding  10  per  cent,  of  sterilised  iodoform1  to 
glycerine,  or  to  a  i-iooo  glycerine  and  sublimate  solution,  should  be 
poured  into  the  wound.  Two  or  three  drachms  of  the  emulsion,  according 
to  the  size  of  the  abscess,  will  suffice,  provided  that  it  be  applied  to  the 
whole  of  the  wall  that  has  been  scraped.  The  wound  is  then  stitched  up 
and  pressure  applied  so  as  to  bring  the  deeper  parts  together  and  to 
avoid  leaving  any  cavity.  When  treated  in  this  way,  the  wound  in  many 
cases  heals  by  first  intention,  and  there  is  no  further  trouble. 

Incision  and  Scraping. — An  alternative  method  is  employed  when  the 
parts  in  front  of  the  abscess  wall  prevent  it  from  being  laid  freely  open,  as 
for  example  in  the  case  of  a  psoas  abscess,  or  when  it  is  very  necessary 
to  avoid  a  large  scar.  Here  the  utmost  that  can  be  done  is  to  make  a 
small  opening  sufficient  to  admit  the  finger  or  the  finger  and  a  sharp  spoon, 
and  then  to  wash  out  the  contents  of  the  abscess  by  a  weak  sublimate 
solution  of  a  strength  of  about  1-6000,  or  even  as  weak  as  1-10,000.  This 
is  best  done  by  introducing  a  Barker's  flushing  spoon  into  the  abscess 
cavity  and  then  turning  the  tap  so  that  the  fluid  flows  through  it.  Of 
course  the  opening  in  the  skin  must  be  large  enough  to  allow  of  the  free 
escape  of  the  fluid  by  the  side  of  the  spoon.  The  latter  is  then  pushed 
into  all  the  recesses  of  the  abscess,  and  when  all  the  fluid  part  has  been 
in  this  way  evacuated,  the  instrument  is  used  for  scraping  the  wall.  This 
is  done  gently  but  thoroughly,  the  whole  of  the  wall  being  gone  over 
systematically,  and,  in  the  example  before  us,  namely  a  psoas  abscess, 
special  care  is  of  course  taken  while  scraping  in  the  forward  and  inward 
direction,  on  account  of  the  thin  covering  that  may  intervene  between  the 
instrument  and  the  peritoneum  or  the  iliac  vein.  After  the  abscess  has 
been  thoroughly  scraped  out,  and  all  the  flakes  have  escaped,  the  spoon 
is  withdrawn,  and  then,  before  proceeding  further,  the  cavity  is  wiped  out 
with  fragments  of  rough  sponge.  Pieces  as  large  as  can  be  forced  into 
the  cavity  are  used ;  they  not  only  soak  up  the  sublimate  solution  which 
remains,  but,  by  twisting  them  round,  their  rough  surface  scrapes  off  any 
tags  of  cheesy  material  which  still  adhere,  and  in  this  way  the  cleansing 
of  the  cavity  is  completed.  About  half  an  ounce  to  an  ounce  of  the 
sterilised  iodoform  and  glycerine  emulsion  referred  to  above  is  then  in- 

1  The  drug  may  be  easily  sterilised  by  keeping  it  in  I -20  carbolic  acid  watery  solu- 
tion in  a  suitable  glass  bottle. 


250  TUBERCULOSIS. 

jected  and  the  skin  wound  stitched  up.  In  doing  this  it  is  well  to  include 
in  the  stitch  not  only  the  skin,  but  also  the  opening  through  the  fascia. 
The  use  of  the  iodoform  emulsion  is  not  absolutely  essential.  Some  cases 
seem  to  do  as  well  without  it ;  on  the  whole,  however,  we  are  of  opinion 
that  better  results  are  obtained  when  it  is  employed. 

In  abscesses  treated  by  this  method  the  skin  incision  usually  heals  by 
first  intention,  and  in  a  certain  number  of  cases  no  re-accumulation  takes 
place.  In  some,  however,  it  is  found  that  after  a  few  weeks  some  deep- 
seated  fluctuation  is  present,  and  this  is  not  remarkable,  since  the  actual 
cause  of  the  abscess,  namely,  the  spinal  disease,  is  but  seldom  accessible 
to  radical  treatment  (i.e.  the  removal  of  the  primary  focus  of  the  disease). 
When  accumulation  takes  place,  and  is  found  after  a  week  or  two  to  be 
increasing,  a  fresh  incision  should  be  made  into  the  sac  and  the  fluid 
again  evacuated.  The  sac  will  be  very  much  smaller  than  it  was  originally, 
and  the  fluid  of  a  brown  serous  character  containing  iodine  and  iodoform. 
The  sac  wall  should  again  be  scraped,  flushed  out,  and  injected  with 
iodoform  and  glycerine  as  in  the  first  operation.  In  many  cases  two 
operations  suffice  to  cure  even  a  large  abscess  of  this  kind.  In  some, 
however,  three  or  even  more  are  requisite,  but  in  the  great  majority  of 
cases  the  patient  can  be  got  well  in  this  way  much  more  quickly  and 
much  more  certainly  than  by  the  old  plan  of  draining  the  abscess.  Some- 
times the  wound,  after  healing  by  first  intention,  gives  way  and  a  small 
sinus  forms  in  the  scar.  Should  this  happen,  the  wound  must  be  opened 
up,  scraped  out  thoroughly  and  stitched  up  as  before,  after  the  sinus  has  been 
carefully  dissected  out.  If  this  be  not  done  the  sinus  may  take  as  long  to 
heal  as  it  was  wont  to  do  when  the  old  plan  of  simple  drainage  was  employed. 
Even  should  a  sinus  again  form,  the  same  procedure  should  be  repeated, 

The  old  plan,  adopted  by  Lord  Lister  when  antiseptic  treatment 
first  came  into  use,  was  to  open  and  drain  these  abscesses,  and,  as  a 
matter  of  fact,  the  great  majority  (from  70  per  cent,  to  80  per  cent.)  so 
treated  healed  ultimately,  provided  they  were  kept  aseptic ;  but  the  healing 
was  tedious,  and  on  an  average  about  eight  months  was  required,  and, 
of  course,  owing  to  the  frequent  dressings  that  were  necessary,  there  was 
constantly  a  danger  of  sepsis. 

It  is  needless  to  say  that  these  operations  must  be  performed  strictly 
antiseptically ;  the  entrance  of  septic  organisms  or  even  of  saprophytes  would 
very  seriously  endanger  the  patient's  life.  Before  the  introduction  of  anti- 
septic treatment  very  few  cases  of  psoas  abscess  recovered. 

Along  with  the  local  treatment  of  these  chronic  abscesses,  the  general 
health  must  be  attended  to  on  the  principles  already  laid  down,  namely, 
good  hygienic  conditions,  absolute  rest  to  the  part,  and  the  administration 
of  cod  liver  oil  and  nourishing  diet.  We  shall  have  to  deal  with  this 
subject  of  chronic  abscess  again  in  connection  with  tuberculous  disease  in 
the  various  organs.  What  has  just  been  said  will  suffice  to  indicate  the 
general  principles  of  the  treatment. 


CHAPTER   XV. 

TUMOURS. 

DEFINITION.  Tumours  may  be  defined  as  localised  swellings  which, 
though  part  of  the  body,  tend  to  grow  continuously  and  quite  independently 
of  it,  and  without  relation  to  any  known  cause.  When  a  tumour  has  formed 
it  continues  to  grow  and  no  means  short  of  its  complete  removal  will 
permanently  arrest  its  development.  It  must  be  distinguished  from  hyper- 
trophy on  the  one  hand  and  from  inflammatory  swellings  on  the  other. 
Hypertrophy  is  a  simple  increase  in  the  size  of  an  organ,  which,  however, 
still  retains  its  natural  form  and  structure  and,  as  far  as  we  know,  its  function  ; 
inflammatory  growths  do  not  possess  any  inherent  power  of  increase,  and 
only  continue  to  grow  as  long  as  the  causes  which  produce  them  continue 
to  act. 

Tumours  grow  either  inside  an  investing  capsule  or  they  may  be  devoid 
of  one,  and  they  then  grow  by  invading  the  surrounding  tissues,  destroying 
them  and  taking  their  place  ;  in  some  cases  minute  portions  of  the  tumour 
may  be  carried  by  the  lymphatics  or  blood  vessels  to  distant  parts  and  there 
give  rise  to  secondary  growths. 

It  is  unnecessary  here  to  enter  fully  into  the  question  of  tumours 
because  their  treatment  must  be  discussed  in  detail  in  connection  with  the 
various  organs  and  tissues  in  which  they  occur.  All  that  we  propose  to 
do  is  to  make  a  few  general  remarks  concerning  them  in  order  to  save 
future  repetition. 

CLINICAL  CLASSIFICATION.— Tumours  may  be  classified  both 
from  a  clinical  and  a  histological  point  of  view.  Clinically  they  are  divided 
into  simple  and  malignant  tumours. 

Simple  tumours. — By  a  simple  tumour,  as  for  example,  an  ordinary 
lipoma,  is  meant  one  which  is  of  slow  growth;  which  does  not,  unless 
situated  in  some  vital  organ,  produce  any  constitutional  disturbance,  such 
as  wasting  or  cachexia;  which  does  not  as  a  rule  cause  pain,  unless  from 
its  situation,  as  for  example  when  it  happens  to  press  upon  nerves  ;  which 
has  no  inherent  tendency,  by  destroying  the  skin  over  it,  to  ulcerate  and 
fungate,  and  only  does  so  when  the  skin  has  been  irritated  from  without. 


252  TUMOURS   OF   THE    CELLULAR   TYPE. 

A  simple  tumour  is  generally  surrounded  by  a  capsule  and  does  not  infiltrate 
the  tissues  around,  nor  does  it  recur  after  being  thoroughly  removed.  It 
is  freely  moveable  and  readily  separable  from  the  surrounding  parts,  unless 
accidental  attacks  of  inflammation  have  occurred  about  it ;  in  structure  it 
resembles  more  or  less  closely  some  of  the  normal  tissues  of  the  body. 

Malignant  Tumours. — A  malignant  tumour,  for  example,  an  epi- 
thelioma,  on  the  other  hand  usually  grows  rapidly  and  after  a  time 
produces  severe  constitutional  effects  known  as  cachexia,  the  patient 
wasting,  becoming  pale  and  sallow,  and  evidently  suffering  from  chronic 
poisoning.  The  growth  is  often  painful  of  itself  apart  from  its  situation, 
and  its  tendency  is  to  undergo  softening,  and,  when  near  the  skin,  to 
destroy  it  and  lead  to  ulceration  and  fungation.  It  is  not  encapsuled, 
any  apparent  capsule  being  really  a  false  one  and  constituting  part  of  the 
tumour  itself.  As  a  rule  it  grows  by  infiltrating  and  destroying  the  sur- 
rounding parts  and  replacing  them  by  tumour  substance,  and  also  by 
producing  secondary  tumours  elsewhere.  Malignant  tumours  are  often 
soft  in  consistence  and  not  freely  moveable  on  account  of  their  infiltrating 
nature.  They  frequently  recur  after  removal.  In  structure  they  differ 
more  or  less  completely  from  normal  tissues. 

HISTOLOGICAL  CLASSIFICATION.— Historically  tumours  are 
divided  into  those  composed  of  cellular  elements  and  those  in  which  the 
structure  is  more  complex  :  the  former  are  again  subdivided  according  to 
the  type  of  cell  that  forms  their  chief  constituent.  On  the  one  hand  they 
are  divided  into  tumours  composed  of  epithelial  tissues,  and  on  the  other 
into  tumours  of  the  connective  tissue  type.  The  tumours  belonging  to 
this  latter  class  are  not  composed  of  cells  alone,  but  they  contain  in 
addition  blood-vessels,  connective  tissue  and  lymphatic  vessels.  So  far 
as  we  know  however  they  are  not  provided  with  true  nervous  elements. 


TUMOURS   OF  THE  CELLULAR  TYPE. 
EPITHELIAL  TUMOURS. 

We  shall  in  the  first  place  refer  very  briefly  to  tumours  in  which  the 
type  of  cell  is  essentially  epithelial.  They  are  due  primarily  to  the  growth 
of  epithelium  which  may  be  regular  or  irregular  and,  if  on  a  free  surface, 
may  remain  heaped  up  in  masses  or  may  penetrate  into  and  infiltrate  the 
tissues  beneath.  The  irregular  infiltrating  form  of  growth  leads  to  the 
formation  of  malignant  tumours,  such  as  carcinomata;  the  regular  non- 
infiltrating  form  gives  rise  to  benign  growths. 

BENIGN  VARIETIES.— Of  this  class  we  have  two  forms,  namely, 
those  where  the  epithelium  is  growing  on  a  free  surface, — the  papillomata, — 
and  those  where  the  growth  is  in  the  substance  of  the  tissues, — the 
adenomata.  The  papillomata  do  not  strictly  belong  to  the  tumour  group 


EPITHELIAL   TUMOURS.  253 

because  many  of  them  are  distinctly  of  irritative  origin  and  sometimes 
spontaneously  disappear;  nevertheless  it  is  most  convenient  to  refer  to 
them  here. 

Papillomata. — This  group  includes  warts,  or  papillomata  proper, 
corns  and  horns.  Warts  on  the  skin  are  usually  hard  and  sessile,  while 
on  the  mucous  membrane  they  are  soft  and  pedunculated.  The  papillae 
of  which  they  are  composed  may  be  single  or  branched,  and  it  is  the 
branched  form  which  gives  rise  to  the  pedunculated  growths  of  which 
the  type  are  those  seen  on  the  prepuce. 

Treatment. — A  simple  and  effectual  method  of  treating  ordinary  hard 
warts  on  the  skin  is  to  pare  away  the  dense  epithelium  on  the  surface 
until  the  vascular  tops  of  the  papillae  are  exposed,  and  then  to  apply 
some  caustic,  so  as  to  destroy  their  bases ;  the  one  which  answers  best 
and  which  leaves  the  least  scar  is  strong  salicylic  acid.  The  most  useful 
form  of  application  is  a  mixture  of  salicylic  acid  with  flexile  collodion  in 
the  proportion  of  100  grains  of  the  former  to  the  ounce  of  the  latter. 
After  the  wart  has  been  shaved  down  so  as  to  expose  the  papillae,  it  is 
dried  and  painted  over  with  the  mixture.  Twelve  hours  later,  as  much  of 
the  collodion  as  will  readily  come  off  is  picked  away  and  a  fresh  layer 
applied,  and  this  is  repeated  night  and  morning ;  in  the  course  of  a  week 
or  ten  days  the  wart* will  generally  be  found  to  have  withered  away.  Should 
the  action  not  be  sufficiently  rapid,  the  wart  should  be  shaved  afresh  from 
time  to  time,  so  as  to  expose  the  base,  and  the  acid  again  applied.  This 
method  may  also  be  sometimes  employed  for  gonorrhceal  warts  covering 
the  prepuce,  where  a  large  raw  area  would  be  left  if  they  were  clipped  off 
with  scissors.  Here  it  is  not  necessary  to  shave  the  wart  before  applying 
the  caustic.  The  prepuce  should  be  retracted,  and  the  wart  thoroughly 
dried  and  then  painted  with  the  salicylic  collodion ;  this  must  be  allowed 
to  dry  thoroughly  before  the  prepuce  is  pulled  forwards,  as  otherwise  a 
sore  on  the  glans  may  be  produced  by  contact  with  the  acid.  In  fact, 
it  is  best,  after  having  painted  the  warts  and  allowed  them  to  dry,  to  intro- 
duce between  the  glans  and  the  prepuce  a  piece  of  dry  boracic  lint,  which 
will  both  absorb  moisture  and  at  the  same  time  prevent  the  contact  of  the 
salicylic  acid  with  the  mucous  membrane  on  the  opposite  side. 

Should  this  method  of  treatment  prove  ineffectual,  the  wart  must  be 
removed  by  the  knife.  When  papillomata  are  sessile  and  are  situated  on 
the  skin,  it  is  not  sufficient  merely  to  clip  them  off,  as  they  will  certainly 
grow  again ;  it  is  usually  necessary  to  excise  them. 

When  the  papillomata  are  pedunculated,  and  the  pedicle  is  narrow,  it 
is  best  to  clip  them  off  at  the  base  with  scissors,  and  then  next  day  and 
for  a  few  days  in  succession,  to  paint  the  cut  surface  with  salicylic  collodion. 
The  papillomata  which  occur  on  mucous  membranes  elsewhere,  such  as  the 
bladder  or  rectum,  must  be  removed  by  special  methods  of  operation; 
these  will  be  described  in  their  appropriate  places. 

Horns. — In  these  cases  the  epithelium  remains  heaped  up  in  masses 


254  TUMOURS   OF   THE   CELLULAR   TYPE. 

over  the  surface  of  the  papillae,  and  becomes  hard  and  stuck  together  by 
some  glutinous  material.  On  breaking  off  the  horn,  a  broad  papillomatous 
base  is  left,  and  this  must  be  dissected  away.  If  this  be  not  done,  the  horn 
will  grow  afresh. 

Corns. — A  corn  is  essentially  due  to  intermittent  pressure,  and  the 
complete  removal  of  all  pressure  will  as  a  rule  lead  first  to  the  peeling  off 
of  the  hard  core  of  the  corn,  and  subsequently  to  the  disappearance  of  the 
whole  trouble.  This  can  be  aided  by  salicylic  collodion  applied  after  paring 
the  corn  in  the  manner  described  in  speaking  of  warts.  A  corn  however 
needs  more  frequent  paring  than  does  a  wart.  If  it  be  at  all  rebellious  to 
the  ordinary  salicylic  collodion,  a  more  certain  and  rapid  effect  is  produced 
by  taking  a  thick  corn  or  bunion  plaster  and,  after  shaving  down  the 
epithelium  as  much  as  possible,  applying  the  plaster  to  it  so  that  the  central 
perforation  is  over  the  base  of  the  corn.  This  is  then  filled  up  with  pure 
salicylic  acid  which  is  kept  in  place  by  a  small  piece  of  ordinary  plaster 
without  any  central  hole  put  on  over  the  corn  plaster.  The  action  of  the 
pure  acid  is  thus  brought  to  bear  directly  upon  the  base  of  the  corn  and 
is  very  effectual. 

Adenomata. — These  tumours  occur  in  connection  with  glands,  and 
their  structure  is  similar  to  that  of  the  gland  in  which  they  develop.  Whether 
they  originate  in  a  hyperplasia  of  the  epithelium  or  of*the  connective  tissue 
is  a  point  which  is  by  no  means  settled,  but  as  a  rule  so  much  fibrous  tissue 
is  present  that  the  term  fibro-adenoma  is  more  appropriate,  or,  if  the  tissue  be 
very  embryonic,  myxo-adenoma.  The  adenomata  are  simple  tumours  which 
are  usually  encapsuled,  and  when  embedded  in  the  substance  of  the  organ 
they  can  generally  be  shelled  out  of  the  capsule  without  any  trouble  and 
without  any  tendency  to  recurrence. 

Treatment. — The  treatment  is  to  remove  them  and  it  is  always  best 
to  take  away  the  capsule.  In  certain  positions  adenomata  become  polypoid, 
for  example,  in  the  rectum,  oesophagus,  etc.,  where  by  their  weight  they 
are  dragged  downwards,  pushing  the  mucous  membrane  before  them.  In 
these  cases  the  removal  of  the  polypoid  growth,  with  ligature  of  the  pedicle 
so  as  to  arrest  the  bleeding,  is  the  proper  treatment. 

MALIGNANT  FORMS.— The  second  great  group  of  epithelial  growths 
is  formed  by  the  carcinomata,  in  which  the  epithelium  grows  in  an  irregular 
manner ;  the  cells  are  larger  than  the  ordinary  epithelial  ones  from  which 
they  originate,  and  the  growths  infiltrate  the  tissues  and  are  not  encapsuled. 
They  are  malignant,  and  the  essential  elements  in  the  tumour  are  the 
epithelial  cells. 

Carcinomata. — The  carcinomata  differ  in  malignancy  and  rapidity  of 
growth  according  to  their  situation,  to  the  character  of  the  epithelium  in 
connection  with  which  they  grow  and  to  other  circumstances  with  which 
we  are  not  well  acquainted.  The  carcinomata  which  spring  from  the  surface 
epithelium  are  generally  spoken  of  as  epitheliomata  and  this  class  includes 
squamous  epithelioma,  and  rodent  ulcer,  growing  from  the  skin,  and  the 


EPITHELIAL   TUMOURS.  255 

cylindrical  epitheliomata,  springing  from  the  intestinal  canal,  etc.  Those 
which  originate  from  glandular  epithelium  are  termed  the  carcinomata  proper. 

The  carcinomata  proper  also  form  several  groups.  There  is  a  very  soft 
form  called  encephaloid  cancer  in  which  the  cells  are  very  numerous  and 
the  fibrous  tissue  very  small  in  amount.  They  are  exceedingly  malignant, 
growing  with  great  rapidity,  and  giving  rise  early  to  secondary  deposits. 
In  marked  contrast  to  these  is  the  atrophic  sdrrhus,  where  the  cells  atrophy 
very  quickly,  and  the  growth  contains  a  large  amount  of  fibrous  tissue  with 
but  few  alveoli  and  cellular  elements.  These  tumours  grow  extremely 
slowly  and  never  attain  any  great  size.  Intermediate  between  these  two 
extremes  are  all  sorts  of  gradations. 

Mode  of  Spread. — The  essential  growing  element  in  the  carcinomata 
is  the  epithelial  cell,  and  the  character  of  the  growth  depends  upon  the 
mode  in  which  these  cells  spread.  In  the  malignant  tumours  the  epithelial 
cells  are  usually  found  enclosed  in  tubular  spaces  termed  alveoli,  which 
are  probably  nothing  else  than  dilated  and  much-altered  lymph  spaces  ;  at 
any  rate  they  communicate  quite  freely  with  the  lymphatics.  The  cells  are 
evidently  derived  from  the  normal  epithelium  of  the  part  in  which  the 
disease  primarily  begins,  but  they  very  soon  increase  in  size  independently 
of  it  and  show  active  processes  of  growth.  They  rapidly  push  their  way 
through  the  limiting  membrane  of  the  normal  epithelium  into  the  tissues 
around  and  there  spread  in  the  lymph  spaces  and  channels  :  at  the  same 
time  it  would  appear  from  recent  investigations  that  they  also  attack  the 
walls  of  the  smaller  veins,  and  spread  into  their  interior  at  a  very  early 
period,  although  metastatic  deposits,  due  to  infection  through  the  blood- 
vessels, seldom  show  themselves  clinically  until  late  in  the  course  of  the  disease. 

After  spreading  into  the  lymphatic  vessels,  the  cells  become  detached 
and  are  soon  carried  with  the  lymph  stream,  and  either  become  lodged  in 
the  course  of  the  vessels  where  the  latter  are  small  and  the  cells  are  large 
or  massed  together  in  groups ;  or  they  are  carried  on  to  the  nearest  lym- 
phatic glands,  where  they  are  caught,  and  there  give  rise  to  secondary 
tumours.  From  the  nearest  lymphatic  glands  again  they  spread  in  the 
same  way  to  others  in  the  neighbourhood,  and  thus  fresh  groups  of  glands 
are  affected.  Ultimately  they  get  into  the  blood-vessels,  either  indirectly 
through  the  thoracic  duct,  or  directly  by  penetrating  the  walls  of  the  veins. 
They  are  thus  finally  deposited  in  various  organs  in  distant  parts  of  the 
body.  Hence,  in  carcinomatous  tumours,  we  have  a  primary  tumour,  a 
secondary  glandular  infection  and  internal  or  metastatic  deposits. 

Furthermore,  certain  special  degenerations  occur  in  some  forms,  such 
as  colloid  degeneration  in  carcinoma  of  the  stomach  and  intestine,  and  a 
form  of  degeneration  accompanied  by  the  deposit  of  pigment  which  is 
generally  spoken  of  as  melanotic  cancer. 

Treatment. — The  only  treatment  of  carcinoma  that  is  at  all  likely  to 
be  of  any  avail  is  operative,  and  the  best  method  in  all  cases  is  by  the 
use  of  the  knife.  As  will  be  mentioned  later,  some  prefer  in  certain  cases, 


256  TUMOURS   OF   THE    CELLULAR  TYPE. 

more  particularly  in  rodent  ulcer,  the  use  of  caustics,  but  in  our  opinion 
there  is  nothing  that  will  compare  with  free  excision  by  means  of  the  knife 
as  a  method  of  cure.  In  any  case,  if  carcinomatous  disease  is  to  be  rooted 
out,  its  mode  of  spread  by  means  of  the  lymphatic  vessels  must  be  borne 
in  mind,  and  as  this  occurs  at  a  very  early  stage,  and  as  the  cells  are 
quite  microscopic,  a  very  wide  area  must  be  included  in  the  operation. 
The  organ  from  which  the  original  growth  springs  should,  if  practicable, 
be  altogether  removed,  because  its  lymphatic  vessels  generally  communicate 
freely  with  each  other,  and  secondary  deposits  have  probably  already  taken 
place  in  various  parts  of  it.  In  addition,  the  nearest  chain  of  lymphatic 
glands  must  also  be  completely  removed,  even  though  they  may  not  be 
noticeably  enlarged. 

It  is  sometimes  difficult  t6  decide  whether  the  lymphatic  tract  inter- 
vening between  the  primary  growth  and  the  glands  should  also  be  removed. 
That  this  should  be  done  in  certain  cases  as,  for  example,  in  breast  cancer, 
is  evident  from  microscopical  researches,  which  have  shown  that  the  lym- 
phatic vessels  passing  from  the  breast  to  the  axillary  glands  are  in  the  great 
majority  of  cases  themselves  affected,  at  any  rate  if  the  disease  be  at 
all  advanced.  On  the  other  hand  there  are  certain  forms  of  carcinoma, 
especially  of  the  squamous  epithelial  type,  where  the  intervening  lymphatics 
do  not  as  a  rule  seem  to  be  readily  infected.  In  epithelioma  of  the 
lip,  for  instance,  although  the  glands  of  the  neck  may  be  enlarged,  it  is 
only  rarely  that  a  secondary  tumour  arises  in  the  course  of  the  lymphatic 
vessels.  The  same  thing  holds  good,  although  perhaps  not  to  so  marked 
an  extent,  in  some  cases  of  epithelioma  of  the  tongue;  in  epithelioma  of 
the  extremities  also,  in  the  leg  for  example,  the  lymphatic  vessels  in  the 
thigh  are  not  usually  affected,  although  the  inguinal  glands  become  involved 
at  a  comparatively  early  period.  Hence,  our  advice  here  is  to  remove 
the  primary  growth  and  the  nearest  lymphatic  glands,  and  then  to  watch 
lest  recurrence  should  take  place  in  the  intervening  tissues.  On  the  other 
hand,  in  breast  cancer  it  is  wiser,  if  we  wish  to  make  sure  of  avoiding 
recurrence,  to  take  away  not  only  the  breast  and  the  axillary  glands,  but, 
in  addition,  all  the  intervening  fat  and  fascia  with  the  lymphatic  vessels 
running  in  them.  Full  details  of  the  steps  of  the  various  operations  will  be 
given  when  dealing  with  the  affections  of  the  individual  parts  and  organs. 


TUMOURS   OF   THE   CONNECTIVE-TISSUE  TYPE. 

These  are  of  two  kinds,  namely,  those  where  the  connective  tissue  is 
of  an  embryonic  character,  such  as  the  sarcomata  and  myxomata,  and 
those  where  the  connective  tissue  is  more  fully  formed,  such  as  the  fibro- 
mata and  lipomata. 

BENIGN  VARIETIES. — The  other  variety  of  embryonic  connective- 
tissue  tumour,  namely,  the  myxoma,  has  the  clinical  characters  of  a  simple 
tumour.  The  myxomata  are  soft,  gelatinous  tumours,  consisting  of  tissue, 


TUMOURS   OF   THE   CONNECTIVE   TISSUE   TYPE.  257 

in  which  are  found  the  characteristic  branched  ramifying  cells,  and  often 
also  a  large  proportion  of  the  round  variety.  They  contain  elastic,  fibrous 
and  fatty  tissue,  and  they  possess  but  few  capillary  blood-vessels.  They  are 
encapsuled,  nodular  and  soft,  and  yield  a  gummy  mucous  fluid  on  scraping. 
They  are  simple ;  they  do  not  tend  to  recur  if  properly  removed ;  they 
grow  in  the  fat,  in  the  subcutaneous  and  intermuscular  tissues,  in  the 
skin,  mucous  membranes,  nerves,  salivary  glands,  etc.,  and  they  occur 
perhaps  most  often  in  the  region  of  the  parotid  gland.  They  are  slow- 
growing,  well  limited,  mobile,  soft  and  semi-fluctuating,  and,  in  the  case 
of  the  nerves,  they  may  be  multiple. 

The  treatment  is  to  remove  the  myxoma  completely,  and  with  it  the 
capsule,  cutting  through  the  healthy  tissue  beyond  the  tumour. 

The  Fibromata  consist  of  fully-formed  connective  tissue;  and  they 
occur  in  two  varieties — the  soft  and  the  hard  fibroma.  The  soft  form  is 
more  cellular  than  the  hard,  and  contains  delicate  fibrous  bundles  not  closely 
approximated.  Its  usual  seat  is  on  the  skin,  where  it  occurs  either  in  the 
form  of  molluscum  fibrosum  or  of  moles.  The  hard  fibroma  is  composed 
of  dense  fibrous  tissue,  showing  a  concentric  arrangement  around  the  vessels. 
The  blood-vessels,  especially  the  veins,  have  no  sheaths,  and  remain  open 
when  divided.  It  is  nodular,  whitish-grey,  creaks  under  the  knife  when 
cut,  and  contains  large  cavernous  venous  spaces.  It  occurs  wherever  there 
is  dense  connective  tissue,  in  the  skin,  in  the  connective  tissues,  especially 
the  fasciae,  in  the  nerves,  periosteum,  etc.  The  fibromata  are  simple 
tumours  which  grow  slowly,  and  are  only  injurious  when  they  press  upon 
important  structures.  They  undergo  various  forms  of  degeneration,  such 
as  serous  infiltration,  calcification,  or  cystic  formation,  the  latter  condition 
resulting  from  fatty  or  mucous  degeneration. 

Treatment.— The  hard  fibromata  should  be  removed,  and,  where  they 
possess  a  definite  capsule,  they  may  generally  be  shelled  out  of  it  with 
ease,  but  in  many  cases,  where  they  occur  in  connection  with  the  fasciae, 
the  capsule  is  not  well  defined,  and  it  is  necessary  to  take  away  this  structure 
along  with  them.  There  is  no  tendency  to  recurrence  after  proper  removal. 
In  the  case  of  soft  fibromata  the  pedunculated  molluscum  fibrosum  can  be 
snipped  off,  and  a  very  small  scar  is  left.  Moles  can  only  be  excised ;  they 
have  no  capsule.  Care  must  be  taken  in  removing  a  large  fibroma  not  to 
cut  into  its  substance,  for  the  vessels  are  embedded  in  the  tissues  and  are 
unable  to  retract,  and  large  cavernous  veins  are  often  present,  and  therefore 
the  bleeding  may  be  very  severe.  This  fact  must  be  borne  in  mind  in 
connection  with  fibromata  in  the  naso-pharynx,  where  it  is  most  essential 
to  avoid  cutting  into  the  substance  of  the  tumour  on  account  of  the  most 
alarming  and  uncontrollable  haemorrhage  which  might  result.  If  such  an 
accident  should  happen,  the  tumour  must  be  ablated  as  quickly  as  possible, 
when  the  vessels  leading  to  it  will  generally  very  rapidly  contract,  and  the 
haemorrhage  will  cease  spontaneously ;  even  if  this  be  not  the  case,  the 
bleeding  points  will  be  much  more  readily  accessible. 


758  TUMOURS. 

The  Lipomata  are  tumours  composed  of  fatty  tissue  which  in  structure 
resembles  normal  fat  and  is  arranged  in  lobules  with  connective  tissue 
between  them.  The  cells  are  somewhat  larger  than  normal  fat  cells.  Some- 
times the  tumours  contain  a  considerable  quantity  of  fibrous  or  mucous 
tissue,  and  they  are  met  with  in  two  forms.  One  is  termed  the  diffuse 
lipoma,  in  which  there  is  a  diffuse  formation  of  coarse  fat  not  surrounded 
by  any  capsule.  It  is  usually  met  with  at  the  back  of  the  neck  on  each 
side  of  the  spine,  or  over  each  anterior  triangle  of  the  neck,  but  it  occurs 
also  over  the  abdomen,  the  arms,  and  so  forth.  More  frequently,  however, 
the  lipomata  form  circumscribed  encapsuled  tumours,  which  are  very  soft 
and  lobulated ;  there  is  often  only  very  delicate  tissue  connecting  the 
lobules  with  the  main  tumour.  They  are  usually  smooth  on  their  deeper 
surface,  and  when  growing  in  the  subcutaneous  tissues  they  penetrate 
among  the  fibrous  bands  connecting  the  under  surface  of  the  skin  with 
the  tissues  beneath,  so  that  the  skin  does  not  move  quite  freely  over 
them.  They  possess  a  more  or  less  well-defined  capsule,  out  of  which 
they  are  readily  shelled.  They  occur  at  all  ages  and  grow  slowly,  and 
are  met  with  especially  in  the  subcutaneous  tissues  where  fat  is  abundant, 
such  as  the  back  of  the  neck,  the  front  of  the  thigh,  over  the  abdomen 
and  the  arms,  in  the  axillae,  in  the  buttocks,  etc. 

Treatment. — (a)  Of  the  encapsuled  variety. — These  growths  are 
readily  removed,  and  shell  out  of  their  capsule  without  any  trouble,  but 
great  care  must  be  taken  to  see  that  none  of  the  outlying  lobules  are 
detached  and  left  behind,  as  lobules  so  left  will  grow  again  and  form 
the  starting  point  of  a  fresh  tumour.  The  best  way  to  remove  a  lipoma 
is  to  squeeze  up  the  tumour  forcibly  between  the  thumb  and  forefinger 
of  the  left  hand  and  make  the  skin  very  tense.  Then,  on  incising  the 
capsule  and  the  parts  over  it  freely,  the  lipoma  is  forcibly  projected 
through  the  incision,  and  its  complete  enucleation  is  insured.  Difficulty 
may  arise  when  they  occur  in  parts  subject  to  pressure.  Here  inflam- 
mation, leading  to  adhesions  between  the  tumour  and  the  skin  covering 
it,  or  the  structures  over  which  it  lies,  is  not  uncommon.  In  such  cases 
care  must  be  taken  to  remove  the  whole  of  the  tumour,  and  it  is  generally 
best  to  remove  the  adherent  skin  as  well. 

(b)  Of  the  diffuse  variety. — The  whole  of  a  diffuse  lipoma  cannot,  as 
a  rule,  be  removed,  but  considerable  improvement,  at  any  rate  as  regards 
appearance,  can  be  effected  by  excising  as  much  of  it  as  possible ;  in 
doing  this  care  must  of  course  be  taken  to  avoid  damage  to  important 
structures,  such  as  nerves,  etc. 

Chondromata  are  tumours  consisting  essentially  of  cartilage,  of  which 
they  may  embrace  all  varieties,  including  the  ramified  cell  form  without 
capsule  usually  found  in  embryonic  conditions  and  in  some  of  the  lower 
animals.  For  the  most  part  the  cartilage  resembles  the  normal  hyaline 
variety,  but  it  differs  from  it  in  that  the  vessels  penetrate  into  the  cartilaginous 
nodules. 


TUMOURS    OF   THE    CONNECTIVE    TISSUE    TYPE. 


259 


The  tumour  is  composed  of  an  aggregation  of  nodules  of  cartilage 
separated  by  fibrous  tissue,  and  is  encapsuled. 

Chondromata  form  rounded  or  lobulated  tumours,  and  in  the  course  of 
their  growth  they  may  surround  various  structures,  such  as  tendons,  nerves, 
or  vessels,  without  actually  destroying  them.  On  section  they  are  usually 
semi-transparent,  greyish-blue,  firm  and  elastic,  or  soft,  and  they  show  a 
lobulated  structure.  They  occur  especially  in  the  phalanges  and  metatarsal 
bones,  in  the  jaw,  in  the  pelvis,  or  about  the  epiphyses  of  long  bones. 
Sometimes  also  they  occur  in  soft  parts,  such  as  the  parotid,  the  sub- 
maxillary  glands,  and  the  testicle ;  but  it  is  a  question  whether  chondromata 
occurring  in  the  soft  tissues  are  not  really  chondrifying  sarcomata  rather  than 
true  chondromata.  At  any  rate  in  the  case  of  the  testicle,  these  tumours 
are  generally  malignant,  and  give  rise  to  secondary  deposits  in  the  lungs, 
and  the  same  chondrification  takes  place  there.  Chondromata  may  undergo 
calcification ;  fatty  or  mucous  degeneration,  leading  to  the  formation  of  cysts 
may  be  met  with  in  them.  They  grow  slowly  and  cause  trouble  chiefly 
from  their  situation,  and,  with  the  exception  of  the  variety  met  with  in 
the  soft  parts  already  mentioned,  they  are  benign  tumours ;  in  the  case  of 
the  phalanges  they  are  often  multiple. 

Treatment. — When  situated  in  the  soft  parts  the  best  treatment  is 
early  extirpation ;  the  capsule  should  not  be  left  behind  because  of  the 
possible  malignant  nature  of  the  tumour.  When  the  growth  springs  from 
a  bone,  it  is  sufficient  to  clip  it  freely  away,  or,  if  situated  in  the  interior, 
to  scrape  it  out  without  performing  amputation.  Care  must  be  taken  to 
do  this  as  completely  as  possible,  because  recurrence  from  lobules  of  the 
cartilage  being  left  behind  is  apt  to  take  place.  Should  this  happen, 
enucleation  may  be  repeated,  or  if  the  bone  be  so  much  destroyed  by  the 
growth  as  to  be  useless,  as  may,  for  example,  be  the  case  in  a  phalanx,  it 
is  best  to  amputate. 

The  OSteomata  are  tumours  composed  of  bony  tissue,  and  are  met 
with  in  two  chief  forms.  The  rarer  of  these  is  the  hard  or  ivory  osteomata 
or  exostosis,  which  is  a  flat  sessile  bony  mass  chiefly  occurring  on  the 
vertex  of  the  skull,  on  one  of  the  bones  of  the  face,  or  in  the  external 
auditory  meatus ;  it  is  of  ivory  hardness,  and  is  formed  of  dense  compact 
bone,  containing  lacunae  and  canaliculi,  but  without  proper  Haversian  canals. 
The  other  form  is  the  spongy  exostosis,  which  resembles  cancellous  bone 
in  structure  and  arises  generally  in  the  neighbourhood  of  the  epiphyseal 
lines.  During  the  period  of  growth  these  spongy  exostoses  are  covered 
with  a  layer  of  cartilage,  and  it  is  from  this  part  of  the  tumour  that 
growth  takes  place.  As  a  rule  this  cartilage  very  quickly  ossifies  at  the 
point  where  the  tumour  joins  the  bone  from  which  it  arises,  and  then 
growth  ceases  there  whilst  it  goes  on  at  the  periphery  of  the  tumour ; 
hence  these  growths  are  usually  pedunculated,  and  they  vary  in  size  and 
are  nodular  on  the  surface. 

Treatment.— The  treatment  of  the  spongy  exostoses  is  to  clip  them 


260  TUMOURS. 

through  at  the  base.  If  this  be  done  where  growth  has  ceased  and 
cartilage  does  not  exist,  recurrence  will  not  take  place.  The  only  danger 
of  this  operation  is  the  possibility  of  sepsis.  In  former  days,  before  anti- 
septic treatment  was  employed,  many  patients  after  operation  developed  a 
suppurative  osteomyelitis,  and  either  died  or  had  to  lose  the  limb  :  hence 
in  operating  the  greatest  care  must  be  taken  in  the  aseptic  management 
of  the  wound. 

The  small  ivory  exostoses  when  growing  on  the  outside  of  the  skull 
are  seldom  of  sufficient  size  to  require  operation.  Their  removal  is  always 
difficult  and  dangerous  because,  owing  to  their  density,  the  force  required 
to  chip  them  off  sometimes  fractures  the  skull.  Hence  it  is  as  a  rule  best 
to  leave  them  alone,  but  in  some  cases,  where  they  are  pressing  on  the 
eye,  ear  or  other  important  parts,  or  growing  internally,  it  may  be  necessary 
to  undertake  their  removal.  If  the  growth  be  comparatively  small  it  may 
be  possible  to  remove  it  by  using  a  large  trephine:  this  is  made  to  encircle 
the  tumour,  and  by  cutting  through  normal  bone  all  around,  the  exostosis 
and  the  base  from  which  it  springs  can  be  removed  entire.  In  the  larger 
growths  this  is  however  impossible,  and  the  only  way  that  offers  a  chance 
of  getting  them  away  without  very  great  trouble  is  to  drill  a  number  of 
holes  through  the  base  of  the  tumour  in  all  directions  by  means  of  a 
dental  engine,  and  then  to  join  these  together  with  a  saw  and  thus 
complete  the  removal ;  in  the  ear  it  is  sometimes  possible,  owing  to  their 
brittleness,  to  break  them  off  by  means  of  a  sudden  smart  tap,  after  their 
base  has  been  drilled.  Attempts  to  remove  them  by  repeated  applications 
of  sulphuric  acid,  as  is  sometimes  recommended,  should  never  be  made : 
it  is  far  better  to  adopt  one  of  the  methods  above  recommended.  If  the 
growth  be  very  diffuse,  and  must  be  removed,  it  may  require  more  than  one 
operation  for  its  satisfactory  treatment. 

Bony  growths  which  do  not  properly  come  under  the  heading  of 
osteoma  are  also  met  with  elsewhere ;  among  these  may  be  mentioned  the 
bony  growths  which  occur  from  irritation  in  the  adductors  of  the  thigh  in 
riders,  or  in  the  deltoid  muscle  in  soldiers ;  they  will  be  dealt  with  later. 

MALIGNANT  FORMS.— The  Sarcomata  form  fleshy  tumours  com- 
posed of  embryonic  connective  tissue.  They  are  rounded,  nodular  and 
generally  have  a  spurious  capsule,  which  is  composed  of  sarcomatous  tissue 
and  must  be  looked  upon  as  an  integral  part  of  the  growth  itself.  They 
vary  in  malignancy,  but  they  all  possess  to  a  greater  or  less  extent  a 
decidedly  malignant  character.  They  may  occur  wherever  there  is  con- 
nective tissue,  and  are  most  frequently  met  with  in  bones,  fasciae,  muscles, 
skin,  the  breast,  the  testicle,  the  uterus,  the  kidney,  the  parotid,  the  nerves 
and  so  forth.  The  cells  vary  in  character  and  the  sarcomata  are  therefore 
sub-divided  into  a  number  of  varieties  according  to  the  general  character 
of  the  cells  composing  them.  In  addition  to  the  cells  there  is  a  certain 
amount  of  inter-cellular  substance  which  varies  in  degree  and  stage  of 
organization  according  to  the  class  of  the  tumour.  The  consistence  and 


TUMOURS   OF   THE   CONNECTIVE   TISSUE   TYPE.  261 

appearance  of  the  tumour  depends  to  a  great  extent  on  the  amount  of 
inter-cellular  substance  present. 

These  growths  are  usually  very  vascular  and  are  especially  rich  in 
capillaries  and  veins.  They  tend  to  undergo  various  degenerations ;  they 
compress  and  destroy  neighbouring  parts,  surround  vessels  and  nerves,  and 
may  lead  to  ulceration  of  the  skin,  either  after  involving  it  or,  more 
commonly,  by  causing  sloughing  from  pressure  and  then  fungating  through 
the  opening  thus  formed.  They  give  rise  to  secondary  tumours  around 
the  primary  one,  or  spread  through  the  medium  of  the  circulation.  The 
secondary  internal  tumours  occur  most  commonly  in  the  lungs  and  liver. 
In  certain  cases,  generally  in  the  softer  and  more  embryonic  varieties,  the 
lymphatic  glands  become  affected,  though  this  is  not  nearly  so  common 
as  in  the  carcinomata. 

Of  the  different  varieties  of  the  sarcomata  we  may  mention  the 
round-celled  sarcoma,  which  is  usually  soft  and  white  like  the  milt  of  fish, 
and  which  is  generally  very  malignant ;  the  spindle-celled  sarcoma,  which 
is  generally  much  firmer,  of  a  greyish  or  yellowish-white  appearance  and 
not  so  malignant  in  its  nature  as  the  round-celled  variety  ;  it  occurs  most 
frequently  in  connection  with  the  fascia? :  the  myeloid  sarcoma,  where,  in 
addition  to  polymorphous  or  spindle  cells,  there  are  large  myeloid  or 
giant  cells.  This  form  is  soft,  of  a  chocolate  colour,  and  generally  con- 
tains large  numbers  of  cysts,  due  to  degeneration  occurring  in  the  first 
instance  in  connection  with  these  myeloid  cells.  It  occurs  in  connection 
with  bones,  more  especially  in  the  interior  of  their  articular  ends,  and 
in  the  lower  jaw,  and  is  usually  an  endosteal  growth.  It  is  the  least 
malignant  of  all  the  sarcomata  and  seldom  gives  rise  to  secondary  tumours  ; 
in  some  cases  it  may  be  removed  without  amputation  and  without  recur- 
rence. Some  authors  separate  these  myeloid  tumours  from  the  sarcomata 
and  place  them  in  a  group  by  themselves. 

The  melanotic  sarcomata  contain  polymorphous  or  spindle-shaped  cells 
in  which  pigmentary  degeneration  occurs  very  early.  They  originate  in 
parts  where  there  is  normally  pigment,  for  example  in  connection  with  the 
skin  or  the  choroid  coat  of  the  eyeball.  They  are  the  most  malignant 
of  all  the  sarcomata  and  affect  the  glands  early,  and  recur  with  great 
rapidity.  Alveolar  sarcoma  is  comparatively  rare.  In  it  the  cells  are 
arranged  in  groups  separated  by  connective  tissue  or  spindle  cells,  giving 
rise  to  an  alveolar  arrangement.  It  usually  occurs  in  connection  with  the 
skin. 

Lastly,  there  is  osteo-sarcoma  which  takes  origin  from  the  periosteum. 
This  form  is  extremely  malignant;  in  it  a  certain  amount  of  ossification 
takes  place  so  that  when  the  affected  bone  is  macerated,  a  considerable 
number  of  spicules  of  osseous  tissue  are  found  projecting  from  its  surface. 
The  secondary  deposits  to  which  this  form  gives  rise  are  very  apt  to 
undergo  similar  ossification.  A  somewhat  analagous  condition  is  seen  ir 
the  variety  known  as  the  chondro-sarcoma,  which  is  a  form  of  sarcoma  met 


262  TUMOURS. 

with  sometimes  in  the  soft  tissues,  such  as  the  testicle  or  the  parotid,  and 
in  which  chondrification  occurs ;  it  is  a  very  malignant  form. 

Treatment. — The  treatment  of  sarcomata  should  in  all  cases  be  free 
excision.  Special  care  must  be  taken  to  see  that  any  capsule  that  the  tumour 
possesses  is  completely  taken  away,  and  in  fact  it  is  well  to  ensure  that  a 
considerable  area  of  healthy  tissue  beyond  the  capsule  is  included  in  the 
removal.  Where  the  sarcomata  arise  in  connection  with  bone,  amputation 
is  generally  necessary,  and  in  cases  of  periosteal  sarcoma  it  is  moreover 
advisable  to  amputate  through  the  joint  above  the  bone  affected,  because 
it  will  be  found  on  microscopical  examination  that  the  growth  generally 
spreads  in  the  periosteum  to  a  considerable  distance  beyond  the  naked-eye 
limits  of  the  tumour,  and  recurrence  is  very  likely  to  take  place  if 
amputation  be  performed  in  the  continuity  of  the  bone. 

Myeloid  tumours  however  form  an  exception  to  the  rule  that  sarcomata 
of  bone  call  for  amputation.  Such  a  procedure  is  rarely  called  for  in  them. 
If  the  growth  be  of  any  size  and  occupy  the  whole  thickness  of  the  bone, 
a  free  excision  of  the  affected  area  will  suffice :  where  the  growth  is  in  the 
articular  end  a  partial  excision  of  the  joint  will  be  called  for.  Where 
however  the  growth  is  small  and  only  occupies  a  small  part  of  the  thick- 
ness of  the  bone,  so  that  sufficient  bone  will  be  left  to  bear  the  weight 
of  the  body,  it  is  not  even  necessary  to  excise.  The  growth  may  in  these 
cases  be  thoroughly  scraped  out  without  much  fear  of  a  recurrence,  though 
it  is  well,  perhaps,  to  take  away  a  thin  slice  of  the  wall  of  the  cavity. 

The  prognosis  in  all  these  tumours,  if  left  to  themselves,  is  very 
grave.  With  the  exception  of  the  myeloid  sarcoma  they  are,  under  any 
circumstances,  always  dangerous  to  life.  On  the  whole,  the  result  of  opera- 
tion is  more  favourable  than  in  carcinoma,  except  in  the  case  of  melanotic 
sarcoma  and  the  osteo-sarco'mata,  which  are  extremely  malignant  forms. 
With  regard  to  the  others,  although  recurrence  is  not  at  all  infrequent,  it 
is  very  often  only  local,  and  in  most  cases  these  secondary  tumours  may 
be  removed  again  and  again  as  soon  as  they  appear.  In  all  cases  a  wide 
sweep  must  be  made  of  the  parts,  and  a  considerable  amount  of  the 
tissues  around  must  be  taken  away.  There  must  be  no  attempt  in  any 
case  to  shell  the  growth  out  of  the  capsule.  As  to  the  mixed  forms,  such 
as  myxo-sarcoma  and  fibro-sarcoma,  the  treatment  is  the  same  as  for  the 
others. 

TUMOURS  COMPOSED  OF  THE  MORE  COMPLEX  TISSUES. 

Amongst  the  tumours  composed  of  more  complex  tissues  are  those 
consisting  of  lymphatic  tissue,  or  lymphomata,  of  muscular  tissue  or 
myomata,  of  nerve  tissue  or  neuromata,  of  blood-vessels  or  angiomata,  of 
lymphatic  vessels  or  lymphangiomata,  and  complex  tumours  and  cysts. 

Lymphomata  are  composed  of  lymphatic  tissue  and  occur  primarily 
in  glands  or  in  parts  where  lymphatic  tissue  is  normally  found ;  they 


TUMOURS  COMPOSED  OF  THE  MORE  COMPLEX  TISSUES.     263 

present  the  same  structure  as  the  lymphatic  glands,  that  is  to  say  a 
delicate  reticulum  with  leucocytes  entangled  in  it.  These  lymphatic 
tumours  vary  in  malignancy,  but  the  typical  lymphadenoma  is  a  very 
malignant  tumour  indeed.  It  occurs  in  glands,  generally  beginning  in  the 
neck  or  the  axilla,  and  very  soon  the  growth  of  adenoid  tissue  spreads 
beyond  the  gland  capsule  and  infiltrates  the  tissues  around.  Adhesion  of 
the  gland  to  the  surrounding  structures  soon  occurs,  and  thus  a  nodular 
mass  is  formed  composed  of  a  multitude  of  glands  united  by  adenoid 
tissue.  Other  groups  of  glands  soon  become  involved  and,  in  addition, 
tumours  composed  of  lymphatic  tissue  may  appear  in  parts  where  this  is 
not  normally  present,  as  for  example  in  bones.  The  disease  goes  on  and 
is  accompanied  by  increasing  pallor  of  the  patient,  but  not  at  first  by 
emaciation.  Ultimately  death  takes  place  from  exhaustion. 

Treatment. — The  treatment  of  lymphadenoma  is  very  unsatisfactory. 
Excision  of  a  mass  of  lymphadenomatous  glands  seldom  arrests  the  progress 
of  the  disease,  even  although  the  whole  of  the  affected  area  may  apparently 
be  entirely  removed.  Other  glands  soon  enlarge  and  recurrence  often 
takes  place  in  the  neighbourhood  of  the  primary  growth.  Hence,  except 
at  a  very  early  stage,  or  where  its  situation  is  such  that  the  growth  causes 
much  suffering  from  pressure  upon  important  organs,  excision  cannot  be 
recommended;  even  at  an  early  stage  it  is  a  procedure  of  very  doubtful 
value. 

Various  drugs  are  said  to  exercise  a  certain  degree  of  restraining  influence 
on  the  growth  of  these  lymphadenomata,  but  the  results  obtained  from 
their  administration  are  also  highly  unsatisfactory.  The  one  usually  ordered 
is  arsenic,  and  it  is  most  commonly  given  in  the  form  of  Fowler's  solution, 
beginning  with  three  minims  in  water  three  times  a  day  after  meals  and 
increasing  it  by  one  minim  every  day  or  two  so  long  as  it  can  be  borne 
without  causing  intestinal  irritation,  a  condition  which  manifests  itself  by 
nausea  vomiting,  colic,  and  diarrhoea.  When  this  occurs  the  arsenic  should 
be  left  off  for  a  few  days,  and  then,  when  the  condition  has  passed  off, 
the  drug  may  again  be  given  in  smaller  doses,  which  should  be  cautiously 
increased.  Some  have  advocated  the  injection  of  Fowler's  solution  into 
the  tumour,  quantities  varying  from  two  to  six  minims  being  introduced 
once  a  day;  there  is  no  convincing  proof  of  the  advantage  of  using  the 
drug  in  this  way.  Abroad,  phosphide  of  zinc,  in  doses  of  a  twentieth  of  a 
grain  in  pill  form  three  times  a  day,  is  very  often  ordered.  On  the  whole, 
arsenic  is  probably  the  most  efficacious  drug,  but  permanent  benefit  can 
hardly  be  hoped  for  from  it. 

Myomata  are  tumours  composed  of  unstriped  muscular  fibre,  and  they 
are  met  with  where  unstriped  muscular  fibre  is  normally  present,  as,  for 
instance,  in  the  uterus,  the  prostate,  the  wall  of  the  oesophagus,  the  stomach, 
and  the  intestines.  In  the  latter  situation  they  generally  project  into  the 
lumen  of  the  gut,  forming  pedunculated  polypi,  covered  by  the  lax  mucous 
membrane.  Myomata  may  be  single,  but  they  are  more  often  multiple ; 


264  TUMOURS. 

they  form  round  tabulated  tumours  with  an  investing  fibrous  capsule,  and 
on  section  they  resemble  fibromata  except  that  they  are  of  a  purplish 
colour.  They  are  generally  very  vascular,  more  especially  at  the  periphery, 
where  large  venous  sinuses  are  numerous.  They  occur  in  adults,  and 
cause  trouble  from  their  size  and  their  tendency  to  bleed. 

Treatment. — This  depends  mainly  upon  their  situation,  and  the  con- 
sideration of  the  treatment  must,  therefore,  be  deferred  until  the  particular 
organs  in  which  they  occur  are  dealt  with. 

Neuromata  are  tumours  composed  of  nerve  tissue.  True  neuromata 
are  very  rare,  if,  indeed,  they  ever  occur;  the  tumours  generally  spoken 
of  as  neuromata  are  inflammatory  thickenings  occurring  in  the  course  of 
nerves,  such,  for  example,  as  the  enlargements  at  the  divided  ends,  or 
tumours,  such  as  myxomata,  fibromata,  or  sarcomata,  occurring  in  the 
neighbourhood  of  and  involving  nerves.  In  connection  with  these  neuro- 
mata may  be  mentioned  the  gliomata,  which  occur  in  the  central  nervous 
system,  and  the  retina,  and  which  are  composed  of  neuroglia.  They  are 
often  vascular,  and,  as  a  rule,  they  are  not  malignant  except  locally;  but 
the  gliomata  which  occur  in  connection  with  the  retina  are  more  malignant, 
and  possibly  ought  to  come  under  the  definition  of  sarcoma. 

The  treatment  of  neuromata  will  be  considered  among  the  affections 
of  nerves.  The  treatment  of  glioma  is  removal  wherever  possible ;  the 
subject  will  be  dealt  with  more  fully  in  connection  with  rumours  of  the 
brain. 

Angiomata  or  naevi  are  composed  of  vascular  tissue,  and  the  essential 
element  in  them  is  the  formation  of  blood-vessels.  The  latter  are  partly 
of  new  formation  and  are  partly  pre-existing  vessels  much  dilated  and 
thickened.  These  tumours  are  divided  into  two  groups — the  simple  or 
capillary,  and  the  cavernous  or  venous  form. 

In  the  capillary  angioma  the  vessels  are  distinct  and  have  well-defined 
walls,  and  the  tumour  simply  consists  of  a  mass  of  dilated  tortuous 
capillaries,  derived  not  only  from  dilatation  of  old  capillaries  but  also  from 
the  formation  of  new  ones.  There  is  no  definite  capsule,  and,  therefore, 
the  tumours  are  not  clearly  marked  off  from  the  surrounding  tissues,  their 
outline  being  irregular  and  somewhat  tabulated.  They  occur  usually  in 
the  skin,  and  may  be  either  upon  its  free  surface  or  in  its  substance,  and 
they  may  spread  from  the  skin  to  the  subcutaneous  tissue.  The  tumour 
generally  presents  a  bright  red  colour,  but  where  the  circulation  is  slow 
it  may  be  somewhat  bluish. 

The  cavernous  angioma,  the  so-called  venous  naevus,  occurs  in  the 
skin,  subcutaneous  tissue,  or  muscles,  and,  like  the  corpus  cavernosum,  is 
composed  of  erectile  tissue.  This  is  made  up  of  large  spaces  comuni- 
cating  with  the  blood-vessels  and  separated  from  each  other  by  septa 
of  unequal  thickness  containing  fibrous  tissue,  remains  of  the  original 
tissue,  elastic  fibres,  striped  and  unstriped  muscle,  fat  cells,  vasa  vasorum, 
lymphatics,  and  nerves,  the  blood  spaces  themselves  being  lined  with 


TUMOURS  COMPOSED  OF  THE  MORE  COMPLEX  TISSUES.     265 

endothelium.  The  great  majority  of  these  venous  naevi  are  congenital  (in 
fact  both  kinds  of  naevi  generally  are),  and  they  may  disappear  as  the 
child  grows  older,  or  they  may  increase  in  size ;  this  is  more  frequently 
the  case  with  the  subcutaneous  or  cavernous  form.  Sometimes  they 
undergo  cystic  degeneration,  the  communication  between  the  blood  spaces 
and  the  vessels  being  obliterated,  and  the  former  then  undergoing  dilata- 
tion, so  that  cysts  of  variable  size  are  formed. 

Treatment. — The  treatment  of  nsevi  may  be  divided  into  (i)  excision, 
and  (2)  the  use  of  methods  which  aim  at  setting  up  inflammation  in  the 
vessels  so  as  to  procure  first  thrombosis  and  ultimately  complete  atrophy 
of  the  vascular  growth. 

(«)  Excision. — Of  excision  it  may  be  at  once  said  that  it  is  certainly 
the  best  possible  method  of  treatment,  and  that  it  should  be  adopted  in 
all  cases  where  it  is  possible  to  carry  it  out.  It  presents  the  following 
great  advantages  over  all  other  methods.  It  is  certain  and  rapid  in  its 
results,  the  affection  being  cured  permanently  within  a  fortnight ;  there 
is  no  pain  attending  the  after-treatment  if  the  wound  be,  as  it  should 
invariably  be,  kept  aseptic ;  no  frequent  change  of  dressings  is  called  for, 
and  there  is  not,  therefore,  the  liability  to  septic  infection  which  is  almost 
inevitable  where  the  opposite  is  the  case.  The  cases  that  are  most  frequently 
met  with  in  practice  are  those  where  there  is  a  moderate  sized  nsevus  of 
the  capillary  variety,  with  or  without  affection  of  the  subcutaneous  struc- 
tures, and  this  form  of  the  affection  is  certainly  best  treated  by  enclosing 
it  in  an  oval  incision  well  free  of  the  growth  and  cleanly  excising  it.  A 
large  naevus  may  not  be  suited  for  excision  either  because  its  size  renders 
the  operation  formidable  from  loss  of  blood,  as  may  be  the  case  in  infants, 
or  from  the  difficulty  that  may  be  met  with  in  bringing  the  edges  together 
subsequently.  In  the  former  case  a  good  plan  is  to  adopt  one  of  the 
methods  to  be  described  immediately  for  procuring  thrombosis,  and  when 
a  sufficient  amount  of  the  tumour  has  thus  been  obliterated  the  rest  may 
be  excised.  In  the  latter  case  most  superficial  njevi  can  be  satisfactorily 
treated  by  excision  followed  by  undermining  of  the  skin  so  as  to  secure 
apposition  of  the  cut  edges.  Where  the  area  is  too  extensive  for  this, 
Thiersch's  skin  grafting  is  preferable  to  the  scarring  that  inevitably  follows 
upon  other  methods.  Even  on  exposed  parts  the  scar  left  by  the  opera- 
tion is  not  so  noticeable  as  that  which  results  from  other  modes  of 
treatment.  As  long  as  the  naevus  is  superficial  it  will  very  rarely  be 
found  too  extensive  for  treatment  by  excision,  especially  if  Thiersch's  grafting 
be  employed ;  several  partial  operations  may  be  required. 

Where  the  surgeon  has  to  deal  with  a  deep-seated  cavernous  nsevus, 
which  is  fairly  limited,  and  does  not  involve  any  important  structure, 
complete  excision  should  also  be  attempted.  There  is  no  particular 
danger  in  excising  a  naevus.  It  should  be  done  strictly  antiseptically,  and 
if  care  be  taken  to  cut  well  beyond  the  tumour,  there  is  no  bleeding  of 
importance,  the  vessels  actually  dilated  being  those  within  the  growth 


266  TUMOURS. 

itself:  those  that  are  divided  in  the  operation  are  merely  the  isolated 
afferent  and  efferent  trunks  which  are  easily  secured  as  they  are  cut  It 
is  of  course  important  not  to  cut  into  the  growth,  as  otherwise  the 
haemorrhage  may  be  profuse  and  controlled  only  with  the  utmost  difficulty. 
Where,  however,  the  naevus  is  partially  superficial  and  partly  deep,  in- 
volving structures  which  cannot  be  readily  removed,  such  as  the  lip,  or 
even  more  important  deeper  structures,  then  excision  is  not  advisable,  and 
in  these  cases  other  methods  must  be  employed ;  of  these  we  shall 
describe  two,  namely  (i)  electrolysis,  and  (2)  injection. 

(&)  Electrolysis. — Of  these  methods  the  former  is  undoubtedly  the 
better.  In  using  electrolysis  for  naevi,  different  effects  are  produced  by  the 
positive  and  negative  poles ;  at  the  positive  pole  a  clot  forms  which  is  firm, 
hard,  and  readily  organised,  whilst  at  the  negative  it  is  soft  and  frothy,  and  of 
little  value  in  the  formation  of  new  tissue.  Hence  it  is  the  positive  pole 
which  is  chiefly  relied  on  to  produce  the  local  effect.  Several  needles 
connected  with  this  pole  should  be  introduced  into  the  swelling  at  various 
points,  especially  in  the  neighbourhood  of  the  veins  which  leave  it.  The 
needles  should  be  insulated  by  means  of  shellac  or  guttapercha,  or  some 
similar  material,  right  up  to  within  a  quarter  of  an  inch  of  the  point,  and 
should  be  pushed  into  the  naevus  until  the  insulated  portion  lies  in  the 
hole  in  the  skin.  If  the  needle  be  not  properly  insulated  where  it  passes 
through  the  skin  it  will  produce  a  slough  which  will  not  only  leave  a  scar 
but  may  also  be  a  point  of  entrance  for  septic  material  into  the  clot. 
Care  must  be  taken  that  the  points  of  the  needles  do  not  approach  too 
near  the  surface  of  the  tumour,  whether  it  be  skin  or  mucous  membrane, 
for,  even  if  they  do  not  actually  perforate  it,  they  may  lead  to  sloughing 
and  subsequent  sepsis;  this  is  particularly  likely  to  happen  if  the  points 
of  several  needles  are  close  together.  If  more  than  one  needle  be  in- 
troduced into  the  naevus,  care  should  be  taken  to  keep  them  parallel  to 
each  other,  so  as  to  ensure  equable  diffusion  of  the  current  and  avoidance 
of  sloughing  (see  Fig.  63).  A  useful  and  ingenious  handle  has  been 
suggested  by  Dr.  Lewis  Jones  for  this  purpose  (see  Fig.  64).  By  its  means 
the  needles  are  kept  parallel  while,  if  it  be  desired  to  insert  both  positive 
and  negative  electrodes  in  the  tumour,  this  can  also  be  done.  Previous  to 
their  introduction  the  needles  should  be  rendered  aseptic  by  boiling;  it  is 
well  not  to  immerse  them  in  strong  carbolic  lotion,  as  that  destroys  the 
insulating  material,  and,  if  steel  needles  are  used,  an  immersion  in  a  1-500 
perchloride  solution  would  damage  the  metal.  As  a  rule  platinum  needles 
are  to  be  preferred;  the  only  drawback  is  that  it  is  impossible  to  get  a 
good  sharp  point  to  them.  After  the  needles  attached  to  the  positive  pole 
have  been  inserted  in  the  manner  just  described,  a  large  flat  pad  attached 
to  the  negative  pole  and  moistened  with  salt  solution  is  placed  on  the  skin 
either  over  the  spine  or  somewhere  in  the  neighbourhood  of  the  naevus.  The 
pad  must  be  moved  from  one  point  to  another  as  the  electrolysis  proceeds,  so 
that  it  shall  not  act  too  long  at  one  spot;  if  it  does,  a  slough  may  result. 


TUMOURS  COMPOSED  OF  THE  MORE  COMPLEX  TISSUES.     267 

In  large  nsevi  both  poles  may  be  buried  in  the  tumour,  the  negative  pole 
being  attached  to  a  single   needle   insulated   as   described  above,  which  is 


FIG.  63. — METHODS  OF  INSERTING  THE  NEEDLES  IN  ELECTROLYSIS  OF  A  N^evus. 
The  upper  figure  shows  the  proper  method,  viz.  where  the  needles  are  kept  parallel,  and 
the  current  is  uniformly  diffused  over  a  large  area,  and  therefore  produces  uniform 
results.  In  the  lower  figure  the  needles  are  in  an  improper  position,  the  current  being 
concentrated  at  the  centre  of  the  tumour,  which  is  therefore  likely  to  slough,  while  the 
periphery  will  hardly  be  acted  upon  at  all.  (Lewis  Jones.) 

also  pushed  into  the  swelling.  For  this  purpose  the  handle  figured  below 
(see  Fig.  64)  is  specially  useful.  The  strength  of  the  current  should  be 
from  40  to  80  milliamperes,  but,  where  three  or  four  needles  are  used,  20 
to  25  will  suffice.  The  current  should  be  continued  for  about  ten  minutes; 


Fie;.  64. — -BIPOLAR  FORK  ELECTRODE.  From  two  to  five  needles  can  be  screwed  into 
the  handle.  They  are  so  arranged  as  to  be  alternately  positive  and  negative,  the  method 
of  insulation  being  shown  in  the  smaller  figure.  (Lewis  Jones  ) 

the  best  criterion  as  to  when  to  discontinue  it  is  perhaps  that  the  nsevus 
is  felt  to  become  firm.  Before  withdrawing  the  needles  the  current  should 
be  reversed  for  a  few  seconds,  as  otherwise  those  connected  with  the 
positive  pole  adhere  firmly  to  the  tissues  and  bleeding  results  from  their 
withdrawal ;  this  is  however  not  of  any  real  moment,  very  slight  pressure 
being  always  sufficient  to  check  it. 


268  TUMOURS. 

The  skin  should  be  thoroughly  disinfected  before  the  operation  (see 
p.  161),  and  after  it  a  little  salicylic  wool  may  be  applied  over  the  puncture, 
fixed  on  with  collodion  and  allowed  to  remain  till  healing  has  taken  place. 
The  electrolysis  causes  a  good  deal  of  pain,  especially  at  the  make  and 
break  of  the  current,  and  when  its  strength  is  increased,  and  it  is  therefore 
well  to  employ  a  general  anaesthetic.  The  current  should  be  increased 
very  gradually  and,  vice  versa,  when  the  operation  is  completed  it  should 
be  gradually  diminished  and  not  shut  off  abruptly,  as  otherwise  consider- 
able shock  may  be  caused.  Similarly,  before  reversing  the  current,  its 
strength  should  be  decreased  gradually  almost  to  nothing.  When  the  naevus 
is  situated  over  the  fontanelle  of  a  young  infant,  a  careful  watch  must  be 
kept  on  the  pulse  as  the  current  is  gradually  increased.  If  any  sign  of 
shock  be  noticed,  the  current  must  be  at  once  diminished  or  shut  off 
entirely. 

As  the  result  of  the  electrolysis  the  ncevus  becomes  hard,  and  this 
hardness  may  sometimes  last  several  weeks  before  it  entirely  disappears. 
If  the  naevus  be  of  any  size,  one  sitting  is  very  rarely  sufficient  for  a  cure, 
and,  therefore,  as  soon  as  the  hardness  has  subsided  sufficiently  to  show 
what  portion  requires  further  treatment,  the  application  is  repeated ;  at 
first  this  may  be  done  at  intervals  of  from  eight  to  ten  days.  After  three 
or  four  sittings,  however,  the  greater  part  of  the  naevus  will  have  become 
firm,  and  then  longer  intervals  must  be  allowed,  because  it  is  impossible 
to  judge  how  much  remains  to  be  done  until  the  hardness  has  more  or 
less  completely  disappeared. 

(c)  Caustics. —Besides  these  extensive  and  important  naevi,  there  are 
the  small  superficial  capillary  stains,  of  small  size  and  insignificant  pro- 
portions in  which  it  is  not  worth  while  to  have  recourse  to  excision.  The 
particular  method  to  be  employed  will  depend  to  a  great  extent  on  the 
size  and  situation  of  the  tumour.  Where  there  is  simply  a  slight  superficial 
naevus  affecting  the  surface  of  the  skin,  the  application  of  some  irritant 
substance  will  suffice.  The  most  popular  is  the  solution  of  ethylate  of  sodium, 
(one  part  to  eight  of  ethylic  alcohol)  which  is  painted  over  the  part  once 
a  day  for  three  or  four  days,  and  which  usually  leads  to  a  sufficient 
amount  of  inflammation  without  causing  any  marked  scarring  of  the  skin. 
It  causes  a  little  pain  at  the  time  of  application,  but  this  is  very  slight  and 
passes  off  immediately ;  no  dressing  is  required.  After  the  application  a 
small  crust  forms,  and  this  is  allowed  to  dry  up  and  drop  off  when,  if  the 
application  has  been  sufficient,  the  naevus  will  be  found  to  be  cured :  should 
any  of  the  naevus  tissue  still  remain,  the  application  may  be  repeated. 
Nitric  acid  is  sometimes  used,  but  it  leaves  a  distinct  scar  and  is  decidedly 
painful  both  at  the  time  of  application  and  subsequently. 

For  very  tiny  naevi  or  red  points,  a  good  method  of  treatment  is  to 
draw  through  them  a  needle  armed  with  a  very  fine  silk  thread  which 
has  been  dipped  in  liquefied  carbolic  acid.  The  skin  all  around  where  the 
needle  enters  should  be  covered  with  lint  dipped  in  a  1-40  solution  of 


TUMOURS  COMPOSED  OF  THE  MORE  COMPLEX  TISSUES.     269 

carbolic  acid,  so  that  the  thread  does  not  come  into  contact  with  it,  as 
otherwise  it  would  cause  a  burn  and  give  rise  to  a  scar.  After  the 
thread  has  been  passed  through  it  is  withdrawn,  pressure  is  applied  for  a 
little  until  the  bleeding  stops,  and  then  the  puncture  is  covered  with 
collodion.  The  old  method  of  vaccinating  upon  these  minute  nsevi  is  a 
good  one  if  they  are  very  small,  superficial,  and  in  a  suitable  situation. 

(d)  Injections. — Another  method  is  by  injection  of  coagulant  materials. 
The  drugs  used — carbolic  acid,  perchloride  of  iron,  etc. — act  by  causing 
thrombosis  of  the  vessels  and  subsequent  obliteration ;  before  injecting  any 
coagulating  material  into  a  nsevus  it  should,  however,  be  an  invariable  rule 
to  see  that  all  connection  with  the  general  circulation  is  completely  cut 
off,  as  otherwise  fatal  embolism  or  even  general  thrombosis  may  occur. 
In  parts  such  as  the  ear  or  lip  this  may  be  done  by  grasping  the  whole 
thickness  of  the  part  on  the  proximal  side  of  the  nsevus  with  rubber-covered 
forceps.  In  most  cases,  however,  the  only  safe  plan  is  to  pass  a  ligature 
or  series  of  ligatures  beneath  the  base  of  the  nsevus,  so  as  to  completely 
command  the  circulation  through  it,  and  then  to  tighten  them  up.  When 
the  nsevus  is  large,  its  base  may  be  transfixed  with  a  hare-lip  pin,  and 
then,  at  right  angles  to  this  pin  and  beneath  it,  a  straight  needle  is  passed 
through  the  tumour,  carrying  a  long  stout  silk  ligature,  the  ends  of  which 
are  of  equal  length.  The  thread  is  drawn  well  through,  and  divided  close 
to  the  needle,  and  thus  two  ligatures  are  left  traversing  the  tissues  beneath 
the  base  of  the  naevus.  The  ends  of  one  of  these  threads  are  brought 
round  beneath  one  end  of  the  hare-lip  pin  and  tied  as  firmly  as  possible, 
and  the  same  is  done  on  the  other  side  with  the  second  thread,  and  in 
this  way  the  nsevus  is  completely  strangulated.  The  object  of  the  hare- 
lip pin  is  to  make  sure  that  the  thread  encircles  the  base  of  the  nsevus  ; 
without  it,  it  is  almost  certain  to  slip,  and  the  circulation  will  not  be 
properly  commanded. 

When  the  nsevus  is  so  extensive  that  the  above  method  would  not 
properly  command  the  circulation  through  it,  its  base  may  be  tied  off  by 
a  succession  of  ligatures  till  the  whole  tumour  is  thoroughly  strangulated. 
Thus,  in  the  case  of  a  nsevus  involving  the  lower  lip,  the  method  will 
be  clear  from  the  accompanying  diagrams  (Figs.  65  and  66) ;  we  may  say 
in  passing  that  this  method  of  ligature  is  of  use  in  other  cases,  such  as 
in  the  removal  of  portions  of  the  omentum.  A  needle  carrying  a  long 
thread,  the  ends  of  which  (A  and  B)  are  of  equal  length,  is  passed  through 
the  whole  thickness  of  the  lip  beyond  the  nsevus  and  near  one  side  of  the 
growth.  It  is  then  passed  back  from  within  outwards  at  a  little  distance 
away,  a  sufficiently  long  loop  being  left,  then  back  again  as  shown  in  the 
diagram,  as  often  as  is  necessary  to  effectually  strangle  the  base.  Thread 
A  is  then  cut  at  b,  c,  and  d,  and  thread  B  at  /  and  g,  and  we  are  thus  left 
with  a  series  of  ligatures,  al>,  b'c,  c'd,  ef,  f'g,  g'h,  which,  when  firmly  tied, 
completely  cut  the  part  off  from  the  general  circulation.  If  it  be  desired 
to  command  the  circulation  through  a  very  extensive  nsevus  situated  upon 


2/0 


TUMOURS. 


a  flat  surface,  it  may  be  done  in  a  manner  quite  similar  to  the  above. 
The  threads  are  passed,  divided,  and  tied  in  an  exactly  similar  manner ; 
the  only  important  difference  is  that,  as  the  deeper  limits  of  the  tumour 
are  not  so  easily  defined  as  when  it  is  situated  upon  the  lip,  greater  care 


FIG.  65. — TEMPORARY  STRANGULATION 
OF  A  N.«vus.  Method  of  poising  the 
sutures.  The  dotted  lines  indicate  the 
threads  traversing  the  thickness  of  the  lip, 
the  continuous  ones  indicating  them  as  they 
emerge  from  the  cutaneous  and  mucous 
surfaces. 


FIG.  66. — TEMPORARY  STRANGULATION 
OF  A  N^EVUS.  Method  of  dividine  the 
ligatures.  It  is  easily  seen  from  the  dia- 
gram how  the  circulation  is  completely 
controlled  by  tying  together  the  corre- 
sponding ends  of  the  ligatures. 


must  be  taken  to  ensure  the  thread  being  passed  below  the  base  of  the 
tumour.  This  is  facilitated  by  pulling  up  the  nsevus  from  the  deeper 
parts  as  the  needle  is  introduced. 

After  having  completely  shut  off  the  tumour  from  the  general  circulation 
by  one  of  these  methods,  small  quantities  of  coagulant  material  may  be 
injected  into  its  interior  at  various  points  by  means  of  a  hypodermic 
syringe.  The  best  material  is  undiluted  carbolic  acid,  and  half  or  a  quarter 
of  a  minim  may  be  injected  in  numerous  places,  the  needle  being  pushed 
into  the  naevus  in  various  directions.  After  the  injection  the  ligatures 
should  be  left  on  for  at  least  ten  minutes,  when  they  may  be  cut  and 
removed ;  by  that  time  coagulation  will  be  complete,  and  there  will  be 
no  risk  of  the  coagulating  material  getting  into  the  circulation  and  causing 
embolism  or  a  general  thrombosis,  both  of  which  accidents  have  happened 
where  coagulants  have  been  injected  without  taking  proper  precautions  to 
shut  off  the  circulation.  In  making  the  injections  care  must  be  taken  not 
to  let  the  point  of  the  needle  approach  too  near  the  surface  ;  if  it  does, 
a  slough  of  the  skin  or  mucous  membrane  and  the  subsequent  introduction 
of  sepsis  may  result  After  the  needle  is  withdrawn,  pressure  is  applied 
over  the  puncture,  which,  when  the  bleeding  ceases,  is  painted  over  with 
collodion.  Other  coagulants,  such  as  perchloride  of  iron,  tincture  of  iodine, 
etc.,  have  been  employed,  but  they  are  not  so  satisfactory  or  so  safe  in 
their  action  as  carbolic  acid. 

When  carbolic  acid  has  been  injected  in  this  way,  the  growth  becomes 
hard,  partly  from  coagulum  in  the  vessels,  and  partly  from  inflammatory 


TUMOURS  COMPOSED  OF  THE  MORE  COMPLEX  TISSUES.     271 

products,  while  later  on  the  new  material  is  gradually  absorbed  and  the 
portion  of  the  naevus  within  reach  of  the  action  of  the  acid  is  cured. 
When  the  thickening  has  subsided,  it  will  be  possible  to  see  what  portions 
have  not  been  acted  on  and  require  further  treatment. 

Ligature. — We  have  not  described  the  treatment  of  nsevi  by  means 
of  ligature  or  strangulation  alone.  This  plan,  which  was  formerly  much 
in  vogue,  is  open  to  so  many  objections  (among  which  the  principal  are 
its  tediousness,  painfulness,  and  the  almost  inevitable  introduction  of 
sepsis)  that  we  cannot  recommend  its  use  in  any  case.  The  strangu- 
lation of  the  naevus  was  effected  in  a  similar  manner  to  that  employed 
for  the  temporary  arrest  of  the  circulation  during  injection  of  carbolic  acid 
(see  p.  269),  but  the  ligatures  were  left  to  cut  their  way  out  by  a  process 
of  ulceration. 

Lymphangiomata  are  tumours  composed  of  lymphatic  vessels  of  new 
formation,  and  it  is  often  very  difficult  to  separate  them  from  lymphang- 
iectasis  or  varicose  lymphatics ;  they  are  congenital  circumscribed  tumours. 
Three  varieties  are  described : 

(1)  The  simple  lymphangioma  consists  of  dilated  lymphatic  vessels  of 
the   size  of  capillary  blood-vessels ;    tumours  of  this   nature   occur   in    the 
perineum,    in    the    sacral   region,    in    the   axilla,    etc.      In    some    cases    the 
dilated  vessels   are   considerably  larger,  as   is   seen   in    the   tongue   in   one 
form  of  macroglossia,  and  also  in  the  lips,  where  it  goes  by  the  name  of 
macrocheilia. 

(2)  Cavernous  lymphangiomata  are  spongy  masses  composed  of  lymph- 
atic vessels   very  closely  resembling   venous   naevi   in   structure,   which    are 
found   in   the   neck,   in   the   sacral   region,   the   lips,  etc.,   generally   in   the 
subcutaneous  tissues,  but  often  deeper. 

(3)  Cystic    lymphangioma    is    a    congenital    agglomeration    of  cysts    of 
various  sizes  which  may  or  may  not  communicate  with  each  other  or  with 
lymphatic  vessels.     They  are  seen  most  frequently  in  the  neck,  where  they 
have  received  the  name  of  hydrocele  of  the  neck ;  they  are  also  met  with  in 
the  perineum,  buttocks,  thorax,  etc. 

Treatment. — Operative  interference,  such  as  excision,  was  generally 
followed  in  former  times  by  suppuration  in  the  lymph  spaces,  and  this  led 
to  extremely  serious  results.  Nowadays  of  course  this  risk  is  greatly 
diminished,  but  in  operating  upon  these  cases  it  is  necessary  to  be 
particularly  careful  as  regards  asepsis.  In  the  majority  of  instances 
electrolysis  is  the  best  treatment,  and  it  should  be  carried  out  in  the  same 
way  as  for  naevi  (see  p.  266).  In  other  cases,  especially  in  the  cystic  forms, 
injections  are  employed,  such  substances  as  iodine  or  undiluted  carbolic 
acid  being  used  in  the  same  way  as  for  hydrocele  of  the  tunica  vaginalis. 
In  the  smaller  forms  excision  is  frequently  practised,  but,  as  has  just  been 
said,  great  care  must  be  taken  to  ensure  the  asepticity  of  the  wound. 

Cysts. — This  is  perhaps  the  best  place  to  refer  to  the  various  forms 
of  cysts ;  the  true  cysts  are  those  of  new  formation,  and  are  not  produced 


2/2 


TUMOURS. 


by  obstruction  of  pre-existing  canals  or  by  degenerative  changes.  Cysts 
may  be  unilocular  or  multilocular,  and  are  found  in  the  ovary  and  in  the 
breast.  In  the  ovary,  multilocular  cysts  form  large  tumours  generally 
composed  of  one  or  two  very  large  cysts,  and  numbers  of  smaller  ones. 
The  walls  are  smooth  and  shining,  the  contents  a  clear  fluid  or  a  turbid, 
glairy  material ;  papillary  outgrowths  are  not  uncommonly  present  in  their 
interior.  The  cysts  of  the  breast  are  similar  in  character,  but  smaller, 
while  the  intra-cystic  growth  may  be  more  markedly  developed.  The  whole 
subject  of  ovarian  and  mammary  cysts  will  be  dealt  with  under  diseases  of 
those  organs.  Other  cysts  are  met  with  as  the  result  of  degeneration  in 
tumours ;  or  again  they  may  be  due  to  the  dilatation  of  previously  existing 
cavities,  such  as  sebaceous  cysts,  hydro-nephrosis,  hydroceles,  etc.,  but 
these  cannot  be  classed  as  true  tumours. 

Complex  Tumours. — Lastly  we  have  complex  tumours,  which  may  be 
solid  or  cystic,  which  are  congenital  and  which  generally  contain  a  variety 
of  tissues.  These  complex  tumours  are  most  frequently  met  with  over  the 
sacrum,  forming  the  sacro-coccygeal  tumours,  and  in  them  may  be  found  a 
variety  of  structures,  such  as  bone,  connective  tissue,  muscle,  nerves, 
cartilage,  epithelium,  etc.,  cysts  also  are  often  present.  Another  form  of 
congenital  complex  tumour  is  the  dermoid  cyst,  the  lining  wall  of  which 
is  composed  of  structures  resembling  skin,  containing  the  skin  glands  as 
well  as  hairs,  and  often  teeth  and  even  bone.  They  occur  in  the  ovary  and 
in  various  parts  where  epithelial  structures  may  have  been  included  during 
development,  more  particularly  in  the  neck  in  connection  with  the  branchial 
clefts  and  about  the  root  of  the  nose  or  the  angular  process  of  the  frontal 
bone. 

The  treatment  of  these  tumours  will  be  referred  to  when  we  treat 
of  the  affections  of  the  organs  in  which  they  occur. 


INDEX. 
PART  I. 


ABSCESS 

acute  circumscribed,  25 
after-treatment  of,  28 
burrowing  of  an,  25 
diverticula  in  an,  25 
drainage  of,  27 

counter-opening  for,  27 
tube,  how  secured  in,  27 
dressing  after  incision  of,  28 
general  treatment  of,  29 
in  gangrene  from  imperfect  innerva- 

tion,  72 

local  treatment  of,  26 
mode  of  extension  of,  25 
opening  of,  26 
symptoms  of,  25 
chronic,  247 

attention  to  general  health  in,  250 
excision  of,  248 
incision  and  scraping  of,  249 
in  relation  to  tuberculosis,  244 
partial  removal  of  wall  of,  248 
treatment  of,  248 

Actual  cautery  in  chronic  inflammation,  19 
A.C.E.  mixture,  103 
advantages  of,  104 
apparatus  and  administration  of,  104 
cases  suitable  for,  104 
followed  by  ether,  106 
objections  to  use  of,  105 
preparation  and  position  of  patient  in 

administration  of,  104 
properties  of,  104 
Aconite  in  acute  inflammation,  14 
Acute 

abscess,  circumscribed,  25 
after-treatment  of,  28 
burrowing  of  an,  25 
diverticula  in  an,  25 
drainage  of,  27 

counter-opening  for,  27 
tube,  how  secured  in,  27 
dressings  after  incision  of,  28 
general  treatment  of,  29 
local  treatment  of,  26 
mode  of  extension  of,  25 


Acute  abscess 

opening  of,  26 
symptoms  of,  25 
bedsore,  72 

fevers,  gangrene  after,  77 
inflammation,  I 
aconite  in,  14 
blood-letting  in,  3 
general,  4 
local,  5 

cause,  removal  of,  3 
cold  in,  8 

dangers  of,  8 
cupping,  dry,  6 
wet,  7 

drinks  in,  13 
drugs  in,  14 

evaporating  lotions  in,  8 
fomentations  in,  1 2 
food  in,  14 
free  incisions  in,  8 
general  symptoms,  2 
heat  in,  1 1 
ice-bag  in,  9 

lead  and  opium  lotion  in,  9 
lead  lotion  in,  9 
leeches,  5 

bleeding  from  bites  of,  6 
Leiter's  tubes  in,  9 

precautions  in  using,  10 
local  changes  in,  2 

treatment  of,  3 
pathology,  I 
position  in,  3 
poultices  in,  1 1 

advantages  and   disadvantages 

of,  12 

prognosis  of,  14 
purgatives  in,  13 
results  at  an  early  period,  I 

a  later  period,  2 
scarification  in,  7 
spongiopilin  in,  13 
symptoms,  2 
treatment  of,  3 
turpentine  stupes  in,  13 


274 


INDEX. 


Acute 

septicaemia,  209 

pathology,    symptoms,    and    treat- 
ment, 210 
suppuration,  24 
causes  of,  24 
in  the  tissues,  24 
tetanus,  221. 
traumatic  gangrene,  78 

treatment  of,  79 
Adenomata,  254 

treatment  of,  254 
Adherent  cicatrix,  226 
tieatment  of,  227 
Age  as  factor  in  production  of  tuberculosis, 

243 

Air,  entry  of,  into  veins,  142 
Alcoholics,  administration  of  anesthetics  in, 

109 

Alveolar  sarcoma,  261 
Ambulatory  treatment  of  ulcers,  56 
Ammonia  in  septic  intoxication,  208 
Amputation  in 

acute  scepticsemia,  210 

traumatic  gangrene,  79 
chronic  scepticsemia,  212 
diabetic  gangrene,  77 
frost-bite,  203 

gangrene  due  to  crushing,  65 
ergot,  78 
obstruction,  72 
lacerated  wounds,  191 
senile  gangrene,  70 
tetanus,  222 
Anaesthesia 

general,  82 

administration  of 

A.C.E.  mixture,  103 
chloroform,  99 
ether,  91 
nitrous  oxide,  87 

and  ether  combined,  97 

oxygen,  90 

after-treatment  of,  1 16 
asphyxia  during,  no 
auscultation  before,  84 
combined  nitrous  oxide  and  ether,  97 
diet  after,  118 
before,  83 
position   of  patient  at   commence- 

of,  84 
preliminary  hypodermic  injections, 

83 

preparation  of  patient  for,  82 
respiratory  troubles  during,  no 
sickness  after,  117 
signs  of  danger  during,  in 

treatment  of,  112 
syncope  during,  no 
local,  118 

advantages  of,  1 1 8 
anaestile  in,  120 
cases  suitable  for,  112 
cocaine  in,  121 
drugs  for,  121 
ether  spray  for,  1 20 
ethyl  chloride  for,  120 
freezing  in,  119 


Anaesthesia,  l<x:al 

infiltration  in,  123 
methods  of,  119 
objections  to,  1 19 
Schleich's  method  of,  123 
Anaesthetic,  choice  of,  factors  determining, 

85,  86,  87 
Anaesthetics,  82 

administration  of,  in 
alcoholics,  109 
intra-cranial  operations,  107 
nose  and  mouth  operations,  107 
severe  operations,  108 
special  cases,  107 
thyroidectomy,  108 
difficulties  and  dangers  in  administering, 

no 

Anaestile,  120 
Angioma,  capillary,  264 

cavernous,  264 
Angiomata,  264 
treatment  by 

carbolic  acid,  268 
caustics,  267 
electrolysis,  266 
ethylate  of  sodium,  268 
excision,  265 
injections,  269 
results  of,  267 
Antipyrin  in  pyaemia,.  215 
Antistreptococcic  serum  in 

acute  septicaemia,  210 
chronic  pyaemia,  216 
erysipelas,  220 
general  septic  infection,  193 
wounds  of  mucous  membranes,  183 
Anti-tetanic  serum,  221 
Aperients  after  operations,  145 

before  operations,  1 26 
Arsenic  in  lymphoma,  263 
Artificial  respiration  in 
anaesthesia,  115 
entry  of  air  into  veins,  143 
poisoning  by  carbonic  oxide,  196 
Aseptic  treatment  of  wounds,  161,  173 
Asphyxial  symptoms  in  anaesthesia,  I IO 
Asthenic  inflammatory  fever,  3 
Atrophic  scirrhus,  255 

Atropine,  injection  of,  before  anaesthesia,  83 
Auscultation  preliminary  to  anaesthesia,  84 

BANDAGE,  Esmarch's,  129 

Martin's,  45 

Barker's  flushing  spoon,  176 
Bedsore,  66 

acute,  72 

prophylaxis,  66 

treatment,  67 

water-bed  in,  66 
Billroth's  mixture,  103 
Blanket  or  button-hole  stitch,  1 58 
Bleeding  from  leech-bites,  6 
Blisters,  counter-irritation  by,  18 

precautions  in  using,  18 

in  treatment  of  ulcers,  45,  60 

treatment  of,  in  burns,  197 
Blood,  symptoms  of  serious  loss  of,  135 
Blood-letting,  3 


INDEX. 


275 


Blood-letting,  general,  4 

local,  5 

Blood-vessels,  waxy  degeneration  of,  211 
Boiling  as  means  of  disinfection,  163 
Boracic  dressing,  wet,  in  ulcers,  48 

lint  and  protective  in  ulcers,  47 
ointment  in  ulcers,  48 
Brandy  in  septic  intoxication,  208 
Bread  poultice,  n 
Breast,  cysts  of,  272 
Burns,  194 

asepsis  in  treatment,  importance  of,  197 

Carron  oil  in,  198 

causes  of  death  after,  195 

constitutional  phenomena  of,  195 

degrees  of,  194 

disinfection  of,  198 

skin-grafting  in,  199 

treatment  of,  general,  196 
local,  197 
in  extremities,  200 

water-bath  in,  199 
Button-hole  stitch,  1 58 
Button  sutures,  157 

CALLOUS  ULCER,  characters  of,  40 

special  points  in  treatment  of,  60 
Cancer,  encephaloid,  255 
Cancrum  oris,  80 
treatment  of,  80 
nitric  acid  in,  81 
Capillary  angioma,  264 
Carbolic  acid 

in  erysipelas,  219 
undiluted  in  diffuse  cellulitis,  30 
naevi,  268,  270 
ulcers,  46,  59 
wounds,  175,  190,  221 
Carbolic  oil  in  treatment  of  ulcers,  47 
Carbonic  oxide  poisoning,  treatment  for,  196 
Carcinomata,  254 

colloid  degeneration,  in,  255 
mode  of  spread  of,  255 
treatment  of,  255 

removal  of  lymphatic  tract  in,  256 
Carron  oil  in  treatment  of  burns,  198 
Caseation  in  relation  to  tuberculosis,  244 
Catgut,  Lister's  sulpho-chromic,  130 
Cautery,  actual,  in  chronic  inflammation,  19 
Corrigan's,  19 
in  chancroid,  239 
haemorrhage,  131 
nsevi,  268 
phagedena,  80 
phagedenic  ulcer,  239 
tuberculous  joints,  247 
Cavernous  angioma,  264 

lymphangiomata,  271 
Cellulitis 

diffuse,  29 

after-treatment  of,  30 
general  treatment  of,  35 
incisions  in,  29 
irrigation  in,  30 
local  treatment  of,  29 
massage  in,  34 
moist  dressings  in,  33 
passive  motion  in,  34 


Cellulitis,  diffuse 

position  in,  34 
icst  in,  34 
symptoms  of,  29 
undiluted  carbolic  acid  in,  30 
water  bath  in,  32 
Celluloid  shields  for  ulcers,  49 
Chancre,  hard  or  Hunterian,  228 

phagedenic,  230 
Chancroid,  238 

definition  of,  238 
symptoms  of,  238 
treatment 

general,  240 
local,  239 

cauterisation  in,  239 
where  phimosis  is  absent,  239 
present,  239 

of  inflamed  inguinal  glands,  240 
Charcoal  poultices,  12 
Cheloid,  224 

causes  of,  224 
cod  liver  oil  in,  225 
excision  of,  225 
scarification  of  scar  in,  225 
treatment  of,  225 
Chilblains,  201 

treatment  of,  202 

flexile  collodion  in,  202 
glycerine  and  belladonna  in,  202 
Chloral,  use  of  in  treatment  of  tetanus,  222 
Chloride  of  calcium  in  haemorrhage,  135 
zinc  in  ulcers,  47 

wounds  of  mucous  mem- 
branes, 182 
Chloroform,  administration  of,  98 

in  severe  tetanus,  222 
after-effects  of,  103 
apparatus  for  administration  of,  100 
cases  suitable  for  administration  to,  99 
Junker's  inhaler  for,  100 

with  tube,  107 

phenomena  during  anaesthesia,  101 
preparation  and  position  of  patient  in 

administration  of,  99 
properties  of,  99 
Skinner's  inhaler  for  100 
Chondromata,  258 

treatment  of,  259 
Chondro-sarcoma,  261 
Chronic 

abscess,  247 

attention  to  general  health  in,  250 
excision  of,  248 
incision  and  scraping  of,  249 
in  relation  to  tuberculosis,  244 
partial  removal  of  wall  of,  248 
treatment  of,  248 
infective  ulcers,  36 
inflammation,  15 

as  factor  producing  tuberculosis,  243 
blisters  in,  18 
causes  of,  15 

removal  of,  16 
changes  in  the  tissues,  15 
counter-irritation  in,  17 
by  actual  cautery,  19 
blisters,  18 


INDEX. 


Chronic  inflammation 

counter-irritation  l>y  blisters, 

precautions  in  applying.  18     ] 
croton  oil,  20 
iodine,  18 
mustard,  17 
setons,  2O 
free  incision  in,  20 
general  treatment  of,  23 
local  treatment  of,  1 6 
massage  in,  21 
nature  of,  15 
position  in,  17 
pressure  in,  21 
removal  of  cause  of,  16 
rest  in,  16 

Scott's  dressing  in,  21 
strapping  in,  21 
symptoms  of,  16 
treatment  of,  1 6 
non-infective  ulcers,  36 
pyaemia,  216 

treatment  of,  216 

antistreplococcic  serum  in,  216 
septicaemia,  211 

amputation  in,  212 
general  treatment  of,  213 
local  operations  in  treatment  of,  211 
treatment  of,  211 

where  focus  of  disease  can 

be  removed,  211 
where  focus  of  disease  can- 
not be  removed,  212 
tetanus,  221 
Cicatrices,  affections  of,  224 

epithelioma  affecting,  227 
Cicatrix,  adherent,  226 

treatment  of,  227 
contracting,  226 
painful,  226 

treatment  of,  226 

Circumscribed  encapsuled  tumours,  258 
Climatic   condition  as  a   factor  in  the  pro- 
duction of  tuberculosis,  244 
Clothing  in  treatment  of  cold,  20 1 
Clover's  large  inhaler,  98 
small  inhaler,  93 

Cocaine  as  a  local  anaesthetic,  121 
dangers  of,  122 
hypodermically,  122 
instillations  of,  121 
painting  with,  122 
spray,  121 
Cod  liver  oil  in  treatment  of  cheloid,  225 

in  tuberculosis,  246 

Cold,  application  of,  in  acute  inflammation,  8 
for  controlling  haemorrhage,  133 
dangers  of,  in  acute  inflammation,  8 
clinical  effects  of,  201 
friction  in  treatment  of,  202 
limits  of  use  of,  in  acute  inflammation,  8 
local  effects  of,  200 
in  Raynaud's  disease,  74 
treatment  of  effects  of,  202 
tuberculosis  as  an  effect  of  exposure  to, 

242 

ulcers  as  effect  of,  201 
Collodion  in  treatment  of  chilblains,  202 


Collodion,  salicylic,  253 

Colloid  degeneration  in  carcinoma,  255 

Complex  tumours,  272 

dermoid  cysts,  272 
Compress,  graduated,  132 
Condylomata,  treatment  of,  235 
Continuous  sutures,  158 
Contracting  cicatrix,  226 

treatment  of,  226 
Contused  wounds  and  contusions,  189 

causes  of,  189 

treatment  of,  189 
Contusions,  189 

causes  of,  189 

treatment  of,  189 
Corns,  254 

plasters  for,  254 
Corrigan's  cautery,  20 
Counter-irritation  in  chronic  inflammation,  17 

by  croton  oil,  20 
Counter-opening  for  drainage,  27 
Croton  oil  for  counter-irritation,  20 
Cupping,  dry,  6 

wet,  7 
Cyanide    gauze    (Lister's)    in    treatment   of 

incised  wounds,  169 
Cystic  lymphangiomata,  271 
Cysts,  271 

dermoid,  272 

sebaceous,  272 

varieties  of,  272 

DANGERS  in  administration  of 

anaesthetics,  in 

chloroform,  103 

ether,  95 

mixtures,  106 

nitrous  oxide,  89 
Deep  structures,  approximation  of,  in  wounds, 

i53»  !7o 

Degrees  of  burn,  194 
treatment  of,  197 

Depletion,  local,  in  inflamed  ulcer,  57 
Dermoid  cysts,  272 
Diabetic  diet,  76 
gangrene,  75 

amputation  in,  77 
treatment  of,  76 
ulcer,  characters  of,  41 

special  points  in  treatment  of,  61 
Diet  after  anesthesia,  1 1 8 
in  pyaemia,  215 

secondary  syphilis,  231 
tetanus,  223 
tuberculosis,  246 

Difficulties  and  dangers  in  anaesthesia,  115 
Diffuse 

cellulitis,  29 

after-treatment  of,  30 
general  treatment  of,  35 
incisions  in,  29 
irrigation  in,  30 
local  treatment  of,  29 
massage  in,  34 
moist  dressings  in,  33 
passive  motion  in,  34 
position  in,  34 
rest  in,  34 


INDEX. 


277 


Diffuse 

cellulitis 

symptoms  of,  29 
undiluted  carbolic  acid  in,  30 
water  bath  in,  32 
lipoma,  258 
Digitaline  in  septic  intoxication,  208 

shock,  141 
Diphtheritic  ulcer,  characters  of,  40 

treatment  of,  59 
Direct  gangrene,  65 
Disinfection  of  burns,  198 

gangrene,  64 
hands  of  operator,  162 
instruments,  163 
lacerated  wounds,  191,  22 1 
ligatures,  163 
skin,  161 
sponges,  164 
ulcers,  46 
Diverticula  in  acute  abscesses,  25 

mode  of  opening,  26 
Drainage  of  acute  abscess,  27 

wounds,  167 
in  septic  intoxication,  207 

traumatic  fever,  209 
lube,  mode  of  introduction  into  abscess,  27 

securing  in  position,  27 
Dressings  in  acute  abscess,  28 
burns,  198 
incised  wounds,  169 

when  to  change  170 
moist,  in  diffuse  cellulitis,  33 
pressure  applied  outside,  170 
Drugs  in  acute  inflammation,  14 
septicaemia,  210 
burns  and  scalds,  197 
diabetic  gangrene,  77 
erysipelas,  218 
frostbite,  203 
lymphoma,  263 
pyaemia,  215 
Raynaud's  disease,  75 
septic  intoxication,  208 
traumatic  fever,  209 
tuberculosis,  246 
Dry  cupping,  6 
gangrene,  63 

ECZEMA,  varicose,  40 

Effleurage  in  massage,  22 

Elastic   bandage  (Martin's)  in  treatment  of 

ulcers,  45 
Electric  bath  in  paralytic  ulcer,  6l 

Raynaud's  disease,  73 
Electricity  in  anaesthesia,  115 
frostbite,  203 
paralytic  ulcer,  61 
Raynaud's  disease,  73 
syncope,  144 

Electrolysis  in  treatment  of 
angiomata,  266 
lymphangiomata,  271 
naevi,  266 

results,  267 
ulcers  from  cold,  203 
Encephaloid  cancer,  255 
Enema,  nutrient,  in  shock,  141 


Enema,  preparatory  to  anesthesia,  83 
Epithelial  tumours,  252 
benign  varieties,  252 
malignant  varieties,  254 
Epitheliomata,  254 

affecting  cicatrices,  227 
cylindrical,  255 
squamous,  254 
Ergot,  gangrene  from,  78 

in  haemorrhage,  135 
Ergotine  in  haemorrhage,  135 
Erysipelas,  216 

gangrenous,  217 
general  treatment  of,  218 
local  treatment  of,  218 
pathology  of,  217 
phlegmonous,  217 
symptoms  of,  216 
treatment  of,  218 

antistreptococcic  serum  in,  220 
carbolic  acid  in,  219 
iodine  in,  218 
Kraske's  method,  218 
lead  lotion  in,  219 
nitrate  of  silver  in,  218 
phlegmonous  cases,  220 
prophylactic,  218 
varieties  of,  217 

Esmarch's  bandage  in  haemorrhage,  129 
Ether,  administration  of,  91 

administration  and  apparatus,  93 

after-effects  of,  96 

cases  suitable  for,  91 

Clover's  inhaler  for,  93 

combined  with  nitrous  oxide,  97 

dangers  in  administration  of,  95 

Ormsby's  inhaler  for,  93 

preceded  by  A.C.E.  mixture,  106 

properties  of,  91 

preparation  and  position  of  patient,  92 

special  points  in  administration  of,  95 

spray  for  local  anaesthesia,  120 

in  septic  intoxication  of  wounds,  208 

shock,  141 

stages  of  anresthetisation  by,  94 
Ethylate  of  sodium  in  treatment  of  ncevi,  268 
Ethyl  chloride  for  local  anaesthesia,  120 
Evaporating  lotions,  8 
Excision  of  cheloid,  225 

chronic  abscess,  248 
glands  in  chancroid,  241 

tuberculosis,  248 
lymphatic  tract  in  carcinoma,  256 
Exostosis,  spongy,  159 

FEEDING  after  operations,  145 

before  operations,  126 
Fever,  asthenic  inflammatory,  2 

hectic,  211 

sthenic  inflammatory,  2 

traumatic,  208 

Fibrin-ferment  in  haemorrhage,  135 
Fibromata,  hard  and  soft,  257 
First  intention,  healing  by,  145 

causes  inimical  to,  150 

of  failure  to  secure,  174 
Fomentations  in  acute  inflammation,  12 
Food  in  acute  inflammation,  14 


278 


INDEX. 


Forceps  for  arrest  of  haemorrhage 

Grieg  Smith's,  132 

Lawson  Tail's,  133 

Spencer  Wells',  132 
Freezing  in  local  anesthesia,  119 
Friction  in  treatment  of  frost-bite,  201 

Raynaud's  disease,  74 
massage,  22 
Frost-bite,  201 

amputation  in,  203 

disinfection  in,  203 

treatment,  203 
Fumigation,  mercurial,  in  syphilis,  234 

GANGRENE,  63 

acute  bedsore  in,  72 
traumatic,  78 

treatment,  79 
after  acute  fevers,  77 

treatment  of,  77 
bedsore,  66 

treatment,  67 
cane  rum  oris,  80 
classification  of,  63 
clinical,  61 
etiological,  65 
definition  of,  63 
diabetic,  75 

treatment,  general,  76 

local,  77 
direct,  65 
dry,  63 
due  to  crushing,  65 

treatment  of,  65 
amputation  in,  65 
general  causes,  75 
pressure,  66 

from  acute  inflammation,  68 
ergot,  78 

treatment  of,  78 
imperfect  innervation,  72 
acute  bedsore  in,  72 
obstruction  of  blood-vessels,  71 
general  treatment  of,  64 
indirect,  68 
infective,  78 
local  treatment  of,  64 
moist,  63 
noma,  80 
phagedenic,  79 

treatment,  80 
Kaynaud's  disease,  72 

treatment,  general,  75 

local,  73 
senile,  68 

treatment,  69 
symptoms  of,  63 
treatment 

general,  64 
local,  64 

Gangrenous  erysipelas,  217 
Glands  in  chancroid,  treatment  of,  240 

tuberculosis,  treatment  of,  248 
Glioma,  264 

Glycerine  and  belladonna  in  chilblain,  202 
Graduated  compress,  132 
Granulating  flaps  in  plastic  operations,  1 80 
wounds,  treatment  of,  186 


Granulations,  healing  by  union  of,  150 
Grieg  Smith's  pressure  forceps,  132 
Guaiacol  in  tuberculosis,  246 

HEMORRHAGE 

means  of  controlling,  128 

bloodless  method,  objections  to,  1 30 

cautery,  131 

cold,  133 

drugs,  135 

Esmarch's  bandage,  129 

fibrin  ferment,  135 

graduated  compress,  132. 

heat,  134 

Horsley's  wax,  133 

ligature,  130 

Lister's  method,  129 

pressure,  132 

torsion,  131 

styptics,  134 

tourniquet,  129 
in  operations,  127 
transfusion  in,  136 
mode  of  spontaneous  arrest  of.  127 
Hsemorrhagic  ulcer,  characters  of,  40 
Hagedorn's  needles,  1 53 
Hands,  disinfection  of,  162 
Hard  fibroma,  257 
Healing,  modes  of,  147 
Heat  in  acute  inflammation,  1 1 

as  a  means  of  controlling  haemorrhage, 

134 
Hectic  fever,  211 

general  treatment  of,  213 

local  treatment  of,  211 
operations  in,  211 
Hereditary  syphilis,  236 
Heredity  as  a  factor  in  production  of  tuber- 
culosis, 243 
Hilton's  method,  27 
Horns,  253 

Horsehair  sutures,  153 

Horsley's  wax  for  controllingkemorrhage,  133 
Hydroceles,  272 

of  neck,  271 
Hydro-nephrosis,  272 
Hygiene  in  treatment  of  tuberculosis,  245 
Hypodermic  injections  of  cocaine,  122 

preparatory  to  anaesthesia,  83 

ICE-BAG  in  acute  inflammation,  9 
precautions  in  applying,  9 

Imperfect  innervation,  gangrene  from,  72 

Imperial  drink,  14 

in  septic  intoxication,  208 
traumatic  fever,  209 

Incised  wounds 

after- progress  of,  172 
apposition  of  the  edges  in,  152 
approximation  of  deeper  structures,  153 
avoidance  of  irritation  of,  160 

movement  in,  160 
classification  of,  152 
exclusion  of  micro-organisms  from,  160 
made  by  surgeon  through  unbroken  skin, 

152 

sutures  in,  153 
buried,  154 


INDEX. 


Incised  wounds 
sutures  in 

button,  157 
button-hole,  158 
coaptation,  stitches  of,  157 
chromicised  catgut,  130 
continuous,  158 
how  to  avoid  stitch  marks,  154 
Lister's  needle  for  wire,  155 
materials  for,  153 

where   there  is  moderate   ten- 
sion, 157 

where  there  is  no  tension,  153 
removal  of,  159 
silkworm  gut,  157 
stitches  of  relaxation,  155 
summary  of  methods  of,  1 59 
sulpho-chromic  catgut  in,  130 
wire,  155 
treatment  of,  Barker's  flushing  spoon  in, 

176 

inflicted  accidentally,  184 
where  edges  have  not  been  brought 

together,  176 

where  sepsis  has  occurred,  175 
undermining  flaps  in,  157 
Incisions  in 

acute  inflammation,  8 
chronic  inflammation,  20 
diffuse  cellulitis,  29 
phlegmonous  erysipelas,  220 
Indirect  gangrene,  68 
Infection,  aerial,  avoidance  of,  166 

septic,  193 

Infective  gangrene,  78 
Infiltration  anaesthesia,  123 
Inflamed  glands,  treatment  of,  in  chancroid, 

240 
Inflamed  ulcer 

characters  of,  39 
special  points  in  treatment  of,  57 
Inflammation,  definition  of,  i 
acute,  I 

aconite  in,  14 
blood-letting  in,  3 
general,  4 
local,  5 

cause,  removal  of,  3 
cold  in,  8 

dangers  of,  8 
cupping,  dry,  6 
wet,  7 

drinks  in,  13 
drugs  in,  14 

evaporating  lotions  in,  14 
fomentations  in,  12 
food  in,  14 
free  incisions  in,  8 
general  symptoms  of,  42 
heat  in,  1 1 
ice-bag  in,  9 
lead  lotion  in,  9 
leeches  in,  5 

bleeding  from  bites  of,  6 
precautions  in  using,  10 
Leiter's  tubes  in,  9 
local  changes  in,  2 
treatment  of,  3 


Inflammation 
acute 

pathology,  I 
position  in,  3 
poultices  in,  1 1 

advantages  and   disadvantages 

of,  12 

prognosis  of,  14 
purgatives  in,  13 
results  at  an  early  period,  I 

at  a  later  period,  2 
scarification  in,  7 
spongiopilin  in,  13 
symptoms  of,  2 
treatment  of,  3 
turpentine  stupes  in,  13 
chronic,  15 

as  factor  producing  tuberculosis.  243 
blisters  in,  18 
causes  of,  1 5 

changes  in  the  tissues,  15 
counter-irritation  in,  17 
by  actual  cautery,  19 
blisters,  18 
croton  oil,  20 
iodine,  18 
mustard,  17 
setons,  20 
free  incisions  in,  20 
general  treatment  of.  23 
local  treatment  of,  16 
massage  in,  21 
nature  of,  15 
position  in,  17 
pressure  in,  21 
removal  of  cause  of,  16 
rest  in,  16 

Scott's  dressing  in,  21 
strapping  in,  21 
symptoms  of,  16 
treatment  of,  1 6 
Inguinal  glands,  excision  of,  in  chancroid,  240 

treatment  when  inflamed,  240 
Injections  in  nsevi,  269 

Injury  as  a   factor  in  production  of  tuber- 
culosis, 242 

Instillations  of  cocaine,  121 
Instruments,  disinfection  of,  163 
Intoxication,  septic,  205 
Intra-cranial    operations,    administration    of 

anaesthetics  in,  107 

Intra-muscular  injection  of  mercury,  234 
Inunction  in  administration  of  mercury,  233 
Iodide  of  iron  in  tuberculosis,  246 
Iodide  of  potassium  in 

hereditary"  syphilis,  237 
tertiary  syphilis,  235 
Iodine,  counter-irritation  by,  17 

in  local  treatment  of  erysipelas,  219 
lodoform  emulsion,  249 

in  wounds  of  mucous  membranes,  182 
septic  wounds,  181 
tuberculosis,  249 
Iron,  in  primary  syphilis,  231 

ulcers,  58 
Irrigation,  in  diffuse  cellulitis,  30 

phlegmonous  erysipelas,  220 
septic  infection,  207 


280 


INDEX. 


Irrigation  of  wounds,  167 
Irritable  ulcer 

characters  of,  39 

treatment  of,  59 

nitrate  of  silver  in,  59 
Irritation,  avoidance  of,  in  wounds,  160 

JONES',  Dr.  Lewis,  bipolar  fork   electrode, 

226 
Junker's  inhaler,  100 

with  tube,  107 

KEITH'S  glass  drainage  tube,  207 
Keyes'  treatment  of  syphilis,  233 
Kraske's  treatment  of  erysipelas,  218 

LACERATED  wounds 
causes,  191 
characters,  190 
treatment,  191 
Lardaceous  disease,  211 
Lawson  Tail's  pressure  forceps,  133 
Lead  and  opium  lotion,  9 
Lead  lotion,  9 

in  erysipelas,  219 

Leech-bites,  arrest  of  bleeding  from,  6 
Leeches,  application  of,  5 

precautions  in,  6 
mode  of  detaching,  5 
Leech-glasses,  5 
Leiter's  tubes  in  acute  inflammation,  9 

dangers  of,  10 
haemorrhage,  134 
Ligature  in  haemorrhage,  130 

in  naevi,  271 

Ligatures,  disinfection  of,  163 
Linseed  meal  poultices,  method  of  prepar- 
ation, ii 

Lipoma,  diffuse  and  circumscribed,  258 
Lister's  cyanide  gauze,  169 

method  of  controlling  haemorrhage,  129 
needle  for  wire  sutures,  155 
Lotions,  evaporating,  8 
Lupus  anatomicus,  192 
Lymphadenoma.  263 
Lymphadenomatous    glands,     excision     of, 

263 

Lymphangioma,  271 

Lymphatics,  removal  of,  in  carcinoma,  256 
Lymphoma,  263 

MACKINTOSHES,  employment  of,  in  oper- 
ations, 165 

Malignant  tumours,  definition  of,  252 
Martin's  bandage,  45 
Massage,  22 

in  cellulitis,  34 

chronic  inflammation,  22 
tuberculosis,  246 
ulcers,  43 

paralytic,  6 1 
from  cold.  203 
Melanotic  sarcoma,  261 
Mercury,  fumigation  by,  234 
"  Gibert's  syrup,"  233 
"  Hutchinson's  formula,"  232 
inunction  of,  233 
intra-muscular  injection  of,  234 


Mercury 

metallic,  232 

modes  of  administration  of,  in 
hereditary  syphilis,  236 
primary  syphilis,  231 
secondary  syphilis,  231 
tertian-  syphilis,  236 
Micro-organisms,  exclusion  of,  from  wounds, 

1 60 

sources  of  infection  by,  161 
Moist  dressings  in  diffuse  cellulitis,  33 

gangrene,  63 
Moles,  treatment  of,  257 
Molluscum  fibrosum,  257 
Morphine  in  tetanus,  223 

preliminary  injection  before  anaesthesia, 

83 
Mucous  membranes,  treatment  of  wounds  of, 

182 
Mustard,  counter-irritation  by,  17 

poultices,  17 
Myeloid  sarcoma,  261 
Myoma,  263 

treatment  of,  264 
Myxoma,  256 

treatment,  257 

NEUROMA,  264 
Nitrate  of  silver  in 

erysipelas,  218 

irritable  ulcer,  59 

weak  ulcer,  58 
Nitric  acid  in 

cancrum  oris,  80 

chancroid,  239 

phagedenic  ulcers,  59 
Nitrous  oxide,  administration  of,  87 

after-eflFects  of,  89 

apparatus  and  administration,  88 

cases  suitable  for,  87 

combined  with  ether,  97 

complications  during  administration  of, 
.  *9 

limitations  to  use  of,  87 

method   of  producing  prolonged  anaes- 
thesia by,  90  . 

phenomena  during  administration  of,  89 

preparation  and  position  in  administra- 
tion of,  87 

properties  of,  87 
Noma,  80 
Nose  and  mouth,  anaesthetics  in  operations 

upon,  107 

Nux  vomica  in  tuberculosis,  246 
Naevus,  capillary,  264 

cavernous  or  venous,  264 

carbolic  acid  in,  268,  270 

caustics  in,  268 

electrolysis  in,  266 

excision  in,  265 

ethylate  of  sodium  in,  268 

injections  in,  269 

ligature  in,  271 

temporary  strangulation  of,  269 

CEDEMA  of  glottis  scarifications  in,  8 
(Edematous  ulcer,  treatment,  59 


INDEX. 


281 


Opening  an  abscess,  method  of,  26 
Open  wounds,  occurrence  of  sepsis  in,  180 
Open  granulating  wounds,  treatment  of,  186 
Operations,  after-treatment  of,  144 

aperients  after,  145 
before,  126 

avoidance  of  aerial  infection  during,  166 

classification  of,  123 

dangers  of,  how  guarded  against,  127 

entry  of  air  into  veins  during,  142 

feeding  after,  145 
before,  126 

haemorrhage  during,  127 

local,  in  hectic  fever,  2 1 1 

mackintoshes  in,  165 

management  of,  125 

sponges  during,  166 

mental  attitude  of  patient  before,  125 

most  favourable  time  for,  126 

precautions  in  dressing  wounds  after,  166 

preparation  of  patient  for,  123 

selection  of  room  for,  127 

shock  during,  138 

syncope  during,  148 
Opisthotonos  in  tetanus,  220 
Ormsby's  inhaler,  93 
Osteomata,  259,  260 
Osteo-sarcoma,  261 

Oval  wounds,  plastic  operations  for,  177 
Ovary,  cysts  of,  272 
Oxygen  in  anaesthesia,  90 

carbonic  oxide  poisoning,  196 

PAIN,  influence  of,  on  shock,  142 
Painful  cicatrix,  226 
Papillomata,  253 

excision  of,  253 

treatment  of,  253 
Paralytic  ulcer 

characters  of,  41 

electricity  in,  61 

electric  bath  in,  61 

massage  in,  6 1 

special  points  in  the  treatment  of,  60 
Parasites  in  wounds,  205 
Passive  motion  in  diffuse  cellulitis,  34 
Pathology  of  tuberculosis,  244 
Perforating  ulcer  of  the  foot,  characters  of,  41 
Petrissage  in  massage,  22 
Phagedena,  79 

treatment,  general,  local,  and  prophyl- 
actic, 80 
Phagedenic  chancre,  treatment  of  acute,  230 

gangrene,  79 

sore,  treatment  of,  239 

ulcer,  characters  of,  40 
treatment  of,  59 

carbolic  acid,  undiluted,  in,  59 
cautery  in,  59 
nitric  acid  in,  59 
special  points  in  treatment  of,  59 
Phagocytosis,  217 
Phenacetin,  use  of,  in  treatment  of  pyaemia, 

2»5 

Phlegmonous  erysipelas,  217 

treatment  of,  220 

Phosphide  of  zinc  in  treatment  of  lympho- 
mata,  263 


Picric  acid  in  burns,  198 
Plastic  operations,  177 

by  curved  incisions,  179 
by  granulating  flaps,- 180 
for  an  oval  wound,  177 
for  quadrilateral  wounds,  178 
for  triangular  wounds,  179 
undermining  flaps  in,  178 
Poisoned  wounds 

treatment  of  lupus  anatomicus,  1 92 
varieties  of,  192 

Poisoning  by  carbonic  oxide,  196 
Position  in  treatment  of 
acute  inflammation,  3 
chronic  inflammation,  17 
diffuse  cellulitis,  34 
ulcers,  43 
Potassa  fusa  in  chronic  inflammation,  20 

phagedenic  ulcer,  59 
Poultices  in  acute  inflammation,  1 1 

advantages  and  disadvantages  of,  1 2 
bread,  II 
charcoal,  12 
mustard,  17 
Pressure  in  arrest  of  bleeding,  132 

chronic  inflammation,  21 
ulcers,  43 
wounds,  170 
Pressure  ulcer 

characters  of,  41 

special  points  in  treatment  of,  60 
"  Primary  syphilis,"  228 
Prophylaxis  in  treatment  of 

acute  traumatic  gangrene,  79 
bedsore,  66 
phagedena,  80 
senile  gangrene,  69 
Psoas  abscess,  treatment  of,  249 
Punctured  wounds,  characters  and  treatment 

of,  188 
Pya3mia,  213 

chronic,  216 
pathology  of,  213 
symptoms  of,  213 
treatment  of,  214 
antipyrin  in,  215 
diet  in,  215 
drugs  for,  215 
phenacetin  in,  215 
quinine  in,  215 

removal  of  thrombosed  vein  in,  214 
salicylate  of  soda  in,  215 
sponging  in,  215 
stimulants  in,  215 

QUADRILATERAL  wounds,  plastic  operations 

for,  178 

Quinine  in  general  septic  infection,  193 
pyaemia,  215 

RAYNAUD'S  disease,  72 

electricity  in,  73 

electric  bath  in,  73 

cold  in,  74 

general  treatment  of,  75 

shampooing  in,  74 

treatment  of,  73 
"  Red  lotion,"  58 


282 


INDEX. 


Respiratory  troubles  during  anaesthesia,  I IO 
Rest  in  chronic  inflammation,  16 

diffuse  cellulitis,  34 

treatment  of  ulcers,  42 

tuberculosis,  247 

Reverdin's  method  of  skin-grafting,  49 
Rodent  ulcer,  254 
Round-celled  sarcoma,  261 
Risus  sardonicus,  220 

SACRO-COCCYGEAL  tumours,  272 

Salicylate  of  soda  in  treatment  of  pyaemia,  215 

Salicylic  collodion,  253 

Saline  solution,  normal,  136 

Saprophytes  in  wounds,  205 

Sarcoma,  260 

treatment  of,  262 

amputation  in,  262 
symptoms  of,  261 
varieties  of,  261 
alveolar,  261 
melanotic,  261 
myeloid,  261 
round-celled,  261 
spindle-celled,  261 
Scalds,  194 

Scalp  wound,  treatment  of,  185 
Scarification  in  acute  inflammation,  7 
of  scar  in  cheloid,  225 
in  oedema  of  the  glottis,  8 
Scarificator,  7 
Schleich's  method  of  infiltration  anaesthesia, 

"3 

Scirrhus,  atrophic,  255 
Scott's  dressing  in  chronic  inflammation,  21 
Sebaceous  cysts,  272 
"  Secondary  syphilis,"  228 
Seegen's  dietary,  76 
Senile  gangrene,  68 

question  of  amputation  in,  70 
prophylactic  treatment  of,  69 
symptoms  of,  68 
treatment  of,  68 
Septicaemia,  acute,  209 

amputation  in,  210 
pathology  of,  210 
symptoms  in,  210 
treatment  of,  2IO 
chronic,  211 

local  treatment  of,  211 
Septic  diseases  of  wounds,  205 

infection,  local  and  general,  193 
intoxication,  205 

ammonia  in,  208 
brandy  in,  208 
digitaline  in,  208 
drainage  tubes  in,  207 
ether  in,  208 
general  treatment  of,  208 
irrigation  in,  207 
local  treatment  of,  206 
strychnine  in,  208 
symptoms  of,  206 
sinuses,  treatment  of,  186 
wounds,  185 
Sepsis  as  a  factor  in  production  of  tuberculosis, 

243 

in  an  open  wound,  180 


Sepsis    in    an    open    wound,    treatment   of, 

181 

Setons,  counter  irritation  by,  20 
Sex  as  a  factor  in  the  production  of  tuber- 
culosis, 243 

Shampooing  in  Raynaud's  disease,  74 
Shields,  celluloid,  in  treatment  of  ulcers,  49 
Shock,  influence  of  pain  on,  141 
treatment,  prophylactic,  139 

when  established,  141 
symptoms  of,  1 38 
Sickness  after  anaesthesia,  117 
Silk  ligatures,  131 

sutures,  154 

Silkworm  gut  sutures,  154 
Silver  wire  sutures,  155 
Simple  lymphangiomata,  271 
tumours,  definition  of,  251 
ulcer,  characters  of,  39 

special  points  in  treatment  of,  57 
Sinuses,  septic,  treatment  of,  186 
Skin,  disinfection  of,  161 
Skin-grafting 

in  treatment  of  burns,  199 
Reverdin's  method,  49 
Thiersch's  method,  50 
in  ulcers,  49 

fresh  wounds,  177 
lacerated  wounds,  191 
preparation  of  ulcer  for,  50 
Skinner  s  inhaler,  100 

Smoking,    prohibition   of,    in  secondary   sy- 
philis, 232 
Soft  fibroma,  257 

sore,  238 

Spencer  Wells'  pressure  forceps,  132 
Spindle-celled  sarcoma,  261 
Sponges,  management  of,  in  operations,  166 

preparation  of,  164 
Sponging  in  acute  septicaemia,  210 

pyaemia,  215 

Spongiopilin  in  acute  inflammation,  13 
Spongy  exostosis,  259 
Spontaneous  arrest  of  bleeding  in  operations, 

127 

Squamous  epithelioma,  254 
Sthenic  inflammatory  fever,  2 
Stimulant  applications  for  weak  ulcer,  58 
Stimulants,  use  of,  in  pyaemia,  215 
septic  intoxication,  208 
shock,  141 

Stitches  of  coaptation,  157 
relaxation,  155 

Stitchmarks,  how  to  avoid,  154 
Strangulation  alone,   treatment  of  a   naevus 

by,  271 

Strangulation,  temporary,  of  a  naevus,  269 
Strapping,  in  chronic  inflammation,  21 

treatment  of  ulcers,  43 
Strong  mixture,  46 

Strychnine,  inj  ection  before  anaesthesia,  84 
in  septic  intoxication,  208 

shock,  140 
Stupe,  turpentine,  13 
Styptics  for  control  of  haemorrhage,  134 
Sulphur    baths    and    spas    in    treatment    of 

syphilis,  236 
Summary  of  causes  of  ulceration,  38 


INDEX. 


Suppuration,  acute,  24 
in  the  tissues,  24 
causes  of,  24 
Sutures,  button,  157 
button-hole,  158 
in  incised  wounds,  153 
where  there  is  great  tension,  154 
moderate  tension,  157 
no  tension,  153 
removal  of,  159 

Syncope  during  anaesthesia,  1 10 
operations,  143 
treatment  of,  144 
Syphilis,  228 

acquired,  228 

primary  stage,  228 

general  treatment,  231 
iron,  231 
mercury,  231 
local  treatment,  230 
secondary  stage,  228 
care  of  teeth,  232 
diet,  231 

prohibition  of  smoking,  232 
geneial  treatment,  231 

mercury  in,  231 
local  treatment,  235 
tertiary  stage,  229 

general  treatment,  235 
local  treatment,  235 
mercury  in,  236 
hereditary,  236 

treatment  of,  236 

iodide  of  potassium  in,  236 
mercury  in,  236 

prophylaxis  in  treatment  of,  229 
sources  of  infection  in,  229 
sulphur  baths  and  spas  in  236 
Swabs,  preparation  and  use  of,  164 

TAPOTEMENT  in  massage,  22 

Teeth,  care  of,  in  secondary  stage  of  syphilis, 

232 
"Tertiary  syphilis,"  229 

local  treatment  of,  235 
Tetanus,  220 

anti-tetanic  serum  in,  221 

causes  of,  221 

causes  of  death  in,  221 

chloral  in,  222 

chloroform  in  severe  cases,  222 

curative  treatment  of,  22 1 

definition  of,  220 

diet  in,  223 

drugs  for,  222 

morphine  in,  223 

prodromata  of,  220 

prophylactic  treatment  of,  221 

symptoms  of,  220 

treatment  of  wound,  222 

varieties  of,  221 
Thiersch's  method  of  skin-grafting,  50 

after-treatment  in,  54 

application  of  grafts  in,  52 

cutting  grafts  in,  52 

dressing  after  application  of  grafts,  53 

fn  fresh  wounds,  177 
lacerated  wounds,  191 


Thiersch's  method  of  skin-grafting 
preparation  of  ulcer  in,  50 
results  after,  55 

time  required  for  cure  after,  55 
Thrombosed  vein,  removal  of,  in  treatment 

of  pyaemia,  214 
Thyroidectomy,  administration  of  anaesthetics 

in,  108 
Torsion  as  a  means  of  controlling  haemorrhage, 

*3i 

Tourniquet  for  controlling  haemorrhage,  129 
Towels,  antiseptic,  in  treatment  of  wounds, 

165 

Transfusion  in  anaesthesia,  116 
haemorrhage,  136 
shock,  141 
Traumatic  fever,  208 
drainage  in,  209 
imperial  drink  in,  209 
treatment  of,  209 
gangrene,  78 

treatment,  79 

Triangular  wounds,  plastic  operations  for.  179 
Trismus,  220 
Tubercle  bacilli,  244 
Tuberculosis,  242 
caseation  in,  244 
causes  inimical  to  retrogressive  changes 

in,  244 

chronic  abscess  in,  244 
definition  of,  242 
drugs  in  treatment  of,  246 
cod  liver  oil,  246 
guaiacol,  246 
mix  vomica,  246 
syrup  of  iodide  of  iron,  246 
factors  in  production  of,  242 
age,  243 

chronic  inflammation,  243 
climatic  conditions,  244 
conditions   connected   with   bacilli, 

243 

cold,  242 

general,  243 

heredity,  243 

injury,  242 

sepsis,  243 

sex,  243 
general  treatment  of,  245 

diet,  246 

hygienic  conditions,  245 

massage,  246 

removal  of  chronic  inflammation,  247 

rest,  247 

pathology  of,  244 
retrogressive  changes  in,  244 
seats  of,  242 
Tumours,  251 

of  cellular  type,  252 
clinical  classification  of,  251 
composed  of  complex  tissues,  262 
connective  tissue  type,  256 

benign  varieties,  256 

malignant  forms,  260 
prognosis  in,  262 
definition  of,  251 

malignant,  252 

simple,  251 


284 


INDEX. 


Tumours 

histological  classification  of,  252 
varieties,  251 

adenomata,  254 
angiomata,  264 
carcinomata,  254 
chondromata,  258 
complex,  272 
corns,  254 
cysts,  271 
epithelial,  252 

benign,  252 

malignant,  254 
epitheliomata,  254 

cylindrical,  255 
fibromata,  257 
horns,  253 
lipomata,  258 
lymphomata.  262 
lymphangiomata.  271 
myomata,  263 
neuromata,  264 
osteomata,  259 
papillomata,  253 
sacro-coccygeal,  272 
sarcoma,  260 
warts,  253 
Turpentine  stupe,  13 

ULCKRATIOX,  36 
Ulcers 

ambulatory  treatment  of,  56 

avoidance  of  irritation  in  treatment  of,  46 

blisters  in  treatment  of,  45 

boracic  lint  and  protective  dressing  in 

treatment  of,  47 

boracic  ointment  in  treatment  of,  48 
callous,  40 

special  points  in  treatment  of,  60 
carbolic  acid,  undiluted,  in  treatment  of, 

46 

carbolic  oil  in  treatment  of,  47 
causes  of,  36 

cold,  201 

constitutional,  38 

contamination,  38 

defective  circulation,  36 

difficulty  in  contraction,  37 

feeble  condition  of  tissues,  37 

imperfect  nervous  supply,  38 

irritation,  38 

movement,  37 

summary  of,  38 

celluloid  shields  in  treatment  of,  49 
chloride  of  zinc  in  treatment  of,  47 
chronic  infective,  36 

non-infective,  36 
classification  of,  36 
constitutional,  41 
dangers  of,  42 
definition  of,  36 
diabetic,  41 

special  points  in  treatment  of,  61 
diphtheritic,  40 

special  points  in  treatment  of,  59 
disinfection  of,  46 
dressing  after  disinfection  of,  47 
due  to  constitutional  causes,  41 


Ulcers 

elastic  bandage  in  treatment  of,  45 
favour  venous  return  in  treatment  of,  43 
from  cold,  20 1 
haemorrhagic,  40 
inflamed,  39 

local  depletion  in  treatment  of,  57 

special  points  in  treatment  of,  57 
irritable,  39 

special  points  in  treatment  of,  59 
Martin's  bandage  in  treatment  of,  45 
massage  in  treatment  of,  43 
paralytic,  41 

special  points  in  treatment  of,  60 
perforating  of  foot,  41 
phagedenic,  40 

special  points  in  treatment  of,  59 
position  in  treatment  of,  43 
practical  points  in  treatment  of,  42 
preparation  of,  in  Thiersch's  skin-grafting, 

So 

pressure  in  treatment  of,  43 
pressure,  41 

special  points  in  treatment  of,  60 
principles  of  treatment  in,  42 
removal  of  cause  of,  42 
rest  in  treatment  of,  42 
rodent,  254 
simple,  39 

special  points  in  treatment  of,  57 
special  points  in  the  treatment  of  various 
forms,  57 

callous,  60 

diabetic,  61 

diphtheritic,  59 

inflamed,  57 

irritable,  59 

paralytic,  60 

perforating,  6 1 

phagedenic,  59 

pressure,  60 

simple,  57 

varicose,  59 

weak,  58 

skin-grafting  in,  49 
strapping  in,  43 
treatment  of,  42 

where  the  patient  cannot  lie  up,  55 
Unna's  bandage  in  treatment  of,  56 
varicose,  40 

special  points  in  treatment  of,  59 
varieties  of,  39 
weak,  39 

special  points  in  treatment  of,  58 
wet  boracic  dressing  in,  48 
Undermining  flaps,  157,  178 
Unna's  bandage  in  treatment  of  ulcers,  56 

VARICOSE  eczema,  4 
ulcer,  60 

excision  of  veins  in,  60 
special  points  in  treatment  of,  59 
Veins,  entry  of  air  into,  142 

treatment,  143 

excision  of,  in  varicose  ulcer,  60 
Venesection,  4 
Venous  njevus,  264 
Vienna  mixture,  103 


INDEX. 


285 


WARTS,  253 

Water-bath  in  treatment  of  burns,  199 

diffuse  cellulitis,  32 
Water-bed,  use  of,  in  bed-sore,  66 
Wax,  Horsley's,  133 
Waxy  degeneration  of  blood-vessels,  211 
Weak  ulcer,  characters  of,  39 

nitrate  of  silver  in,  58 

red  lotion  in,  58 

special  points  in  treatment  of,  58 

stimulant  applications  for,  58 
Wet  cupping,  7 
Wire  sutures,  silver,  155 
Wounds  already  septic,  185 

cases  requiring  drainage,  168 

classification  of  incised,  1 52 

contused,  189 

drainage  of,  167 

dressing  of,  169 

when  to  change  dressings,  170 
how  to  change  dressings,  172 

exclusion  of  micro-organisms  from,  160 

infective  diseases  of,  205 

inflicted  accidentally,  184 

irrigation  of,  167 

lacerated,  190 

modes  of  healing  of,  147 
by  blood-clot,  148 
first  intention,  145 

causes  of  failure,  174 
causes  inimical  to,  150 


Wounds  already  septic 
modes  of  healing  of 

by  granulations,  148  • 

union  of,  150 
under  a  scab,  148 
of  mucous  membranes,  182 

antistreptococcic  serum  in,  183 
chloride  of  zinc  in,  182 
iodoform  in,  182 
parasites  in,  205 
pressure  in,  170 
poisoned,  192 
punctured,  188 
saprophytes  in,  205 
sepsis  in  open,  180 
septic  intoxication  of,  205 
septic  sinuses  in,  186 
skin-grafting  in  fresh  wounds,  177 
sources  of  infection  by  micro-organisms, 

161 

that  cannot  be  kept  aseptic,  182 
treatment  of  sepsis  in  an  open,  181 
aseptic  method,  161,  173 
disinfection  of  skin,  161 
hands,  162 
instruments,  163 

where   edges  are   not   brought    to- 
gether, 176 
sepsis  occurs,  175 
without  antiseptics,  1 73 


GI.ASdOW  :    PRINTED   AT   THE   UNIVERSITY  PRESS   BY   ROBERT   MACI.UHOSE    AND    CO. 


Date  ijue 


PRINTED   IN   U.S.*.  CAT        NO.      24       161 


,.U.SI.?.UJH.E.R1?E.GIONAL  LIBRARY  FACILITY 


A  000  511  649  6 


¥0  100 
C531m 
1899 
v.l 
Cheyne,  William  W 

A  manual  of  surgical  treatment 


WO  100 
C531m 

1899 
v.l 

jCheyne,  William  W 

A  manv.al  of  surgical  treatment 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


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